Cognitive informatics and nursing care plans

FOURTH EDITION

NURSING INFORMATICS and the Foundation of Knowledge

The Pedagogy Nursing Informatics and the Foundation of Knowledge, Fourth 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:

Key Terms » Accessibility » Cognitive activity » Data » Data gatherer » Enumerative

approach » Expert systems

» Industrial Age » Information » Information Age » Information user » International

Classification of Nursing Practice

» Knowledge » Knowledge

builder » Knowledge user » Knowledge worker » Ontological

approach

» Reusability » Standardized Nurs-

ing Terminology » Technologist » Terminology » Ubiquity » Wisdom

1. Trace the evolution of nursing informatics from concept to specialty practice.

2. Relate nursing informatics metastructures, con- cepts, and tools to the knowledge work of nursing.

3. Explore the quest for consistent terminology in nursing and describe terminology approaches that

accurately capture and codify the contributions of nursing to health care.

4. Explore the concept of nurses as knowledge workers.

5. Explore how nurses can create and derive clinical knowledge from information systems.

Objectives

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Introduction Those who followed the actual events of Apollo 13, or who were enter- tained by the movie (Howard, 1995), watched the astronauts strive against all odds to bring their crippled spaceship back to Earth. The speed of their travel was incomprehensible to most viewers, and the task of bringing the spaceship back to Earth seemed nearly impossible. They were experienc- ing a crisis never imagined by the experts at NASA, and they made up their survival plan moment by moment. What brought them back to Earth safely? Surely, credit must be given to the technology and the spaceship’s ability to withstand the trauma it experienced. Most amazing, however, were the traditional nontechnological tools, skills, and supplies that were used in new and different ways to stabilize the spacecraft’s environment and keep the astronauts safe while traveling toward their uncertain future.

This sense of constancy in the midst of change serves to stabilize experi- ence in many different life events and contributes to the survival of crisis and change. This rhythmic process is also vital to the healthcare system’s stability and survival in the presence of the rapidly changing events of the Knowledge Age. No one can dispute the fact that the Knowledge Age is changing health care in ways that will not be fully recognized and under- stood for years. The change is paradigmatic, and every expert who ad- dresses this change reminds healthcare professionals of the need to go with the fl ow of rapid change or be left behind.

As with any paradigm shift, a new way of viewing the world brings with it some of the enduring values of the previous worldview. As health care continues its journey into digital communications, telehealth, and wearable technologies, it brings some familiar tools and skills recognized in the form of values, such as privacy, confi dentiality, autonomy, and nonma- lefi cence. Although these basic values remain unchanged, the standards for living out these values will take on new meaning as health professionals confront new and different moral dilemmas brought on by the adoption

Ethical applications of Informatics Dee McGonigle, Kathleen Mastrian, and Nedra Farcus

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ChapTEr 5

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Key Terms Found in a list at the beginning of each chapter, studying these terms will create an expanded vocabulary.

Objectives Providing a snapshot of the key information encountered in each chapter, the objectives serve as a checklist to help guide and focus study. Objectives can also be found within the text’s online resources.

Introductions Found at the beginning of each chapter, the introductions provide an overview highlighting the importance of the chapter’s topic. They also help keep students focused as they read.

Key Terms » Artificial

intelligence » Brain » Cognitive

informatics » Cognitive science » Computer science

» Connectionism » Decision making » Empiricism » Epistemology » Human Mental

Workload (MWL) » Intelligence

» Intuition » Knowledge » Logic » Memory » Mind » Neuroscience » Perception

» Problem solving » Psychology » Rationalism » Reasoning » Wisdom

1. Describe cognitive science. 2. Assess how the human mind processes and gener-

ates information and knowledge.

3. Explore cognitive informatics. 4. Examine artificial intelligence and its relationship

to cognitive science and computer science.

Objectives

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Summaries Summaries are included at the end of each chapter to provide a concise review of the material covered, highlighting the most important points and describing what the future holds.

uncertainty to the situational factors and personal beliefs that must be considered cre- ates a need for an ethical decision-making model to help one choose the best action.

Ethical Decision Making Ethical decision making refers to the process of making informed choices about ethical dilemmas based on a set of standards differentiating right from wrong. This type of decision making reflects an understanding of the principles and standards of ethical decision making, as well as the philosophic approaches to ethical decision making, and it requires a systematic framework for addressing the complex and often contro- versial moral questions.

As the high-speed era of digital communications evolves, the rights and the needs of individuals and groups will be of the utmost concern to all healthcare profession- als. The changing meaning of communication, for example, will bring with it new concerns among healthcare professionals about protecting patients’ rights of confi- dentiality, privacy, and autonomy. Systematic and flexible ethical decision-making abilities will be essential for all healthcare professionals.

Notably, the concept of nonmaleficence (“do no harm”) will be broadened to include those individuals and groups whom one may never see in person, but with whom one will enter into a professional relationship of trust and care. Mack (2000)

82 ChapTEr 5 Ethical Applications of Informatics

rESEarCh BrIEF

Using an online survey of 1,227 randomly selected respondents, Bodkin and Miaoulis (2007) sought to describe the characteristics of information seekers on e-health websites, the types of information they seek, and their perceptions of the quality and ethics of the websites. Of the respondents, 74% had sought health in- formation on the Web, with women accounting for 55.8% of the health informa- tion seekers. A total of 50% of the seekers were between 35 and 54 years of age. Nearly two thirds of the users began their searches using a general search engine rather than a health-specific site, unless they were seeking information related to symptoms or diseases. Top reasons for seeking information were related to dis- eases or symptoms of medical conditions, medication information, health news, health insurance, locating a doctor, and Medicare or Medicaid information. The level of education of information seekers was related to the ratings of website quality, in that more educated seekers found health information websites more understandable, but were more likely to perceive bias in the website information. The researchers also found that the ethical codes for e-health websites seem to be increasing consumers’ trust in the safety and quality of information found on the Web, but that most consumers are not comfortable purchasing health products or services online.

The full article appears in Bodkin, C., & Miaoulis, G. (2007). eHealth information quality and ethics issues: An exploratory study of consumer perceptions. International Journal of Pharmaceuti- cal and Healthcare Marketing, 1(1), 27–42. Retrieved from ABI/INFORM Global (Document ID: 1515583081).

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practices are sometimes more harmful than beneficial). A case in point is the long-standing practice of instilling endotracheal tubes with normal saline before suctioning (O’Neal, Grap, Thompson, & Dudley, 2001). Based on the evidence gathered through several studies, the potentially deleterious effects of this practice have become widely recognized. Conceivably, a meta-analysis approach to clinical studies will be expedited by convergence of large clinical data repositories across care settings, thereby making available to practitioners the collective contribu- tions of health professionals and longitudinal outcomes for individuals, families, and populations.

Nurses need to be engaged in the design of CIS tools that support access to and the generation of nursing knowledge. As we have emphasized, the adoption of clini- cal data standards is of particular importance to the future design of CIS tools. We are also beginning to see the development and use of expert systems that implement knowledge automatically without human intervention. For example, an insulin pump that senses the patient’s blood glucose level and administers insulin based on those data is a form of expert system. The expert system differs from decision support tools in that the decision support tools require the human to act on the information pro- vided, whereas the expert system intervenes automatically based on an algorithm that directs the intervention. Consider that as CISs are widely implemented, as standards for nursing documentation and reporting are adopted, and as healthcare IT solutions continue to evolve, the synthesis of findings from a variety of methods and world- views becomes much more feasible.

BOX 6-3 CaSE STuDy: CaSTINg TO ThE FuTurE

In the year 2025, nursing practice enabled by technology has created a profes- sional culture of reflection, critical inquiry, and interprofessional collaboration. Nurses use technology at the point of care in all clinical settings (e.g., primary care, acute care, community, and long-term care) to inform their clinical deci- sions and effect the best possible outcomes for their clients. Information is gath- ered and retrieved via human–technology biometric interfaces including voice, visual, sensory, gustatory, and auditory interfaces, which continuously monitor physiologic parameters for potentially harmful imbalances. Longitudinal records are maintained for all citizens from their initial prenatal assessment to death; all lifelong records are aggregated into the knowledge bases of expert systems. These systems provide the basis of the artificial intelligence being embedded in emerging technologies. Smart technologies and invisible computing are ubiqui- tous in all sectors where care is delivered. Clients and families are empowered to review and contribute actively to their record of health and wellness. Invasive diagnostic techniques are obsolete, nanotechnology therapeutics are the norm, and robotics supplement or replace much of the traditional work of all health professions. Nurses provide expertise to citizens to help them effectively manage their health and wellness life plans, and navigate access to appropriate informa- tion and services.

122 ChaPEr 6 History and Evolution of Nursing Informatics

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The Future The future landscape is yet to be fully understood, as technology continues to evolve with a rapidity and unfolding that is rich with promise and potential peril. Box 6-3 helps us to imagine what future practice might entail. It is anticipated that computing power will be capable of aggregating and transforming additional multidimensional data and information sources (e.g., historical, multisensory, experiential, and genetic sources) into CIS. With the availability of such rich repositories, further opportunities will open up to enhance the training of health professionals, advance the design and application of CDSs, deliver care that is informed by the most current evidence, and engage with individuals and families in ways yet unimagined.

The basic education of all health professions will evolve over the next decade to incorporate core informatics competencies. In general, the clinical care environments will be connected, and information will be integrated across disciplines to the benefit of care providers and citizens alike. The future of health care will be highly dependent on the use of CISs and CDSs to achieve the global aspiration of safer, quality care for all citizens.

The ideal is a nursing practice that has wholly integrated informatics and nursing education and that is driven by the use of information and knowledge from a myriad of sources, creating practitioners whose way of being is grounded in informatics. Nursing research is dynamic and an enterprise in which all nurses are engaged by virtue of their use of technologies to gather and analyze findings that inform specific clinical situations. In every practice setting, the contributions of nurses to health and well-being of citizens will be highly respected and parallel, if not exceed, the preemi- nence granted physicians.

Summary In this chapter, we have traced the development of informatics as a specialty, defined nursing informatics, and explored the DIKW paradigm central to informatics. We also explored the need for and the development of standardized terminologies to capture and codify the work of nursing and how informatics supports the knowledge work of nursing. This chapter advanced the view that every nurse’s practice will make contributions to new nursing knowledge in dynamically interactive CIS environ- ments. The core concepts associated with informatics will become embedded in the practice of every nurse, whether administrator, researcher, educator, or practitioner. Informatics will be prominent in the knowledge work of nurses, yet it will be a sub- tlety because of its eventual fulsome integration with clinical care processes. Clinical care will be substantially supported by the capacity and promise of technology today and tomorrow.

Most importantly, readers need to contemplate a future without being limited by the world of practice as it is known today. Information technology is not a panacea for all of the challenges found in health care, but it will provide the nursing profes- sion with an unprecedented capacity to generate and disseminate new knowledge at rapid speed. Realizing these possibilities necessitates that all nurses understand and leverage the informatician within and contribute to the future.

Summary 123

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This text is designed to include the necessary content to prepare nurses for prac- tice in the ever-changing and technology-laden healthcare environments. Informatics competence has been recognized as necessary in order to enhance clinical decision making and improve patient care for many years. This is evidenced by Goossen (2000), who reflected on the need for research in this area and believed that the focus of nursing informatics research should be on the structuring and processing of patient information and the ways that these endeavors inform nursing decision mak- ing in clinical practice. The increased use of technology to enhance nursing practice, nursing education, and nursing research will open new avenues for acquiring, pro- cessing, generating, and disseminating knowledge.

In the future, nursing research will make significant contributions to the devel- opment of nursing science. Technologies and translational research will abound, and clinical practices will continue to be evidence based, thereby improving patient outcomes and decreasing safety concerns. Schools of nursing will embrace nursing science as they strive to meet the needs of changing student populations and the increasing complexity of healthcare environments.

Summary Nursing science influences all areas of nursing practice. This chapter provided an overview of nursing science and considered how nursing science relates to typical nursing practice roles, nursing education, informatics, and nursing research. The Foundation of Knowledge model was introduced as the organizing conceptual framework for this text. Finally, the relationship of nursing science to nursing informatics was discussed. In subsequent chapters the reader will learn more about how nursing informatics supports nurses in their many and varied roles. In an ideal world, nurses would embrace nursing science as knowledge users, knowledge managers, knowledge developers, knowledge engineers, and knowl- edge workers.

ThOUGhT-prOVOKING QUeSTIONS

1. Imagine you are in a social situation and someone asks you, “What does a nurse do?” Think about how you will capture and convey the richness that is nursing science in your answer.

2. Choose a clinical scenario from your recent experience and analyze it using the Foundation of Knowledge model. How did you acquire knowledge? How did you process knowledge? How did you generate knowledge? How did you dis- seminate knowledge? How did you use feedback, and what was the effect of the feedback on the foundation of your knowledge?

18 ChapTer 1 Nursing Science and the Foundation of Knowledge

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Research Briefs These summaries encourage students to access current research in the field.

Thought-Provoking Questions Students can work on these critical thinking assign­ ments individually or in a group. In addition, students can delve deeper into concepts by completing these exercises online.

Case Studies Case studies encourage active learning and promote critical think­ ing skills. Students can ask questions, analyze situations, and solve problems in a real­world context.

FOURTH EDITION

Dee McGonigle, PhD, RN, CNE, FAAN, ANEF Director, Virtual Learning Experiences (VLE) and Professor Graduate Program, Chamberlain College of Nursing Member, Informatics and Technology Expert Panel (ITEP) for the American Academy of Nursing

Kathleen Mastrian, PhD, RN Associate Professor and Program Coordinator for Nursing Pennsylvania State University, Shenango Sr. Managing Editor, Online Journal of Nursing Informatics (OJNI)

NURSING INFORMATICS and the Foundation of Knowledge

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Library of Congress Cataloging-in-Publication Data Names: McGonigle, Dee, editor. | Mastrian, Kathleen Garver, editor. Title: Nursing informatics and the foundation of knowledge/[edited by] Dee McGonigle, Kathleen Mastrian. Description: Fourth edition. | Burlington, MA: Jones & Bartlett Learning, [2018] | Includes bibliographical references and index. Identifiers: LCCN 2016043838 | ISBN 9781284121247 (pbk.) Subjects: | MESH: Nursing Informatics | Knowledge Classification: LCC RT50.5 | NLM WY 26.5 | DDC 651.5/04261--dc23

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Special Acknowledgments

We want to express our sincere appreciation to the staff at Jones & Bartlett Learning, especially Amanda, Christina, and Carolyn, for their continued encouragement, assistance, and support during the writing process and publication of our book.

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Preface xvi Acknowledgments xix Contributors xxi

SECTION I: BUILDING BLOCKS OF NURSING INFORMATICS 1

1 Nursing Science and the Foundation of Knowledge 7 Dee McGonigle and Kathleen Mastrian Introduction 7 Quality and Safety Education for Nurses 16 Summary 18 References 19

2 Introduction to Information, Information Science, and Information Systems 21 Kathleen Mastrian and Dee McGonigle Introduction 21 Information 22 Information Science 25 Information Processing 26 Information Science and the Foundation of Knowledge 27 Introduction to Information Systems 28 Summary 32 References 33

3 Computer Science and the Foundation of Knowledge Model 35 Dee McGonigle, Kathleen Mastrian, and June Kaminski Introduction 35 The Computer as a Tool for Managing Information and Generating Knowledge 36 Components 38 What Is the Relationship of Computer Science to Knowledge? 53 How Does the Computer Support Collaboration and Information Exchange? 54 Cloud Computing 57 Looking to the Future 59 Summary 61 Working Wisdom 61 Application Scenario 62 References 62

Contents

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4 Introduction to Cognitive Science and Cognitive Informatics 65 Kathleen Mastrian and Dee McGonigle Introduction 65 Cognitive Science 65 Sources of Knowledge 68 Nature of Knowledge 69 How Knowledge and Wisdom Are Used in Decision Making 69 Cognitive Informatics 70 Cognitive Informatics and Nursing Practice 71 What Is AI? 72 Summary 73 References 74

5 Ethical Applications of Informatics 77 Dee McGonigle, Kathleen Mastrian, and Nedra Farcus Introduction 77 Ethics 78 Bioethics 79 Ethical Issues and Social Media 80 Ethical Dilemmas and Morals 81 Ethical Decision Making 82 Theoretical Approaches to Healthcare Ethics 83 Applying Ethics to Informatics 86 Case Analysis Demonstration 91 New Frontiers in Ethical Issues 95 Summary 96 References 97

SECTION II: PERSPECTIVES ON NURSING INFORMATICS 99

6 History and Evolution of Nursing Informatics 105 Kathleen Mastrian and Dee McGonigle Introduction 105 The Evolution of a Specialty 106 What Is Nursing Informatics? 108 The DIKW Paradigm 109 Capturing and Codifying the Work of Nursing 112 The Nurse as a Knowledge Worker 117 The Future 123 Summary 123 References 124

7 Nursing Informatics as a Specialty 127 Dee McGonigle, Kathleen Mastrian, Julie A. Kenney, and Ida Androwich Introduction 127 Nursing Contributions to Healthcare Informatics 127

Contents ix

Scope and Standards 128 Nursing Informatics Roles 129 Specialty Education and Certification 131 Nursing Informatics Competencies 133 Rewards of NI Practice 138 NI Organizations and Journals 138 The Future of Nursing Informatics 139 Summary 141 References 142

8 Legislative Aspects of Nursing Informatics: HITECH and HIPAA 145 Kathleen M. Gialanella, Kathleen Mastrian, and Dee McGonigle Introduction 145 HIPAA Came First 145 Overview of the HITECH Act 148 How a National HIT Infrastructure Is Being Developed 153 How the HITECH Act Changed HIPAA 154 Implications for Nursing Practice 161 Future Regulations 165 Summary 165 References 166

SECTION III: NURSING INFORMATICS ADMINISTRATIVE APPLICATIONS: PRECARE AND CARE SUPPORT 169

9 Systems Development Life Cycle: Nursing Informatics and Organizational Decision Making 175 Dee McGonigle and Kathleen Mastrian Introduction 175 Waterfall Model 178 Rapid Prototyping or Rapid Application Development 180 Object-Oriented Systems Development 181 Dynamic System Development Method 181 Computer-Aided Software Engineering Tools 184 Open Source Software and Free/Open Source Software 184 Interoperability 185 Summary 186 References 187

10 Administrative Information Systems 189 Marianela Zytkowski, Susan Paschke, Kathleen Mastrian, and Dee McGonigle Introduction 189 Types of Healthcare Organization Information Systems 190 Communication Systems 190 Core Business Systems 191 Order Entry Systems 193 Patient Care Support Systems 194

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Interoperability 195 Aggregating Patient and Organizational Data 197 Department Collaboration and Exchange of Knowledge and Information 202 Summary 203 References 204

11 The Human–Technology Interface 207 Dee McGonigle, Kathleen Mastrian, and Judith A. Effken Introduction 207 The Human–Technology Interface 208 The Human–Technology Interface Problem 211 Improving the Human–Technology Interface 212 A Framework for Evaluation 221 Future of the Human–Technology Interface 221 Summary 223 References 224

12 Electronic Security 229 Lisa Reeves Bertin, Kathleen Mastrian, and Dee McGonigle Introduction 229 Securing Network Information 229 Authentication of Users 231 Threats to Security 232 Security Tools 237 Offsite Use of Portable Devices 238 Summary 241 References 242

13 Workflow and Beyond Meaningful Use 245 Dee McGonigle, Kathleen Mastrian, and Denise Hammel-Jones Introduction 245 Workflow Analysis Purpose 245 Workflow and Technology 249 Workflow Analysis and Informatics Practice 251 Informatics as a Change Agent 256 Measuring the Results 258 Future Directions 259 Summary 260 References 261

SECTION IV: NURSING INFORMATICS PRACTICE APPLICATIONS: CARE DELIVERY 263

14 The Electronic Health Record and Clinical Informatics 267 Emily B. Barey, Kathleen Mastrian, and Dee McGonigle Introduction 267 Setting the Stage 268

Contents xi

Components of Electronic Health Records 269 Advantages of Electronic Health Records 274 Standardized Terminology and the EHR 278 Ownership of Electronic Health Records 280 Flexibility and Expandability 283 Accountable Care Organizations and the EHR 285 The Future 285 Summary 287 References 287

15 Informatics Tools to Promote Patient Safety and Quality Outcomes 293 Dee McGonigle and Kathleen Mastrian Introduction 293 What Is a Culture of Safety? 294 Strategies for Developing a Safety Culture 296 Informatics Technologies for Patient Safety 301 Role of the Nurse Informaticist 313 Summary 315 References 317

16 Patient Engagement and Connected Health 323 Kathleen Mastrian and Dee McGonigle Introduction 323 Consumer Demand for Information 324 Health Literacy and Health Initiatives 325 Healthcare Organization Approaches to Engagement 327 Promoting Health Literacy in School-Aged Children 329 Supporting Use of the Internet for Health Education 330 Future Directions for Engaging Patients 335 Summary 337 References 338

17 Using Informatics to Promote Community/Population Health 341 Dee McGonigle, Kathleen Mastrian, Margaret Ross Kraft, and Ida Androwich Introduction 341 Core Public Health Functions 343 Community Health Risk Assessment: Tools for Acquiring Knowledge 345 Processing Knowledge and Information to Support Epidemiology and Monitoring Disease Outbreaks 347 Applying Knowledge to Health Disaster Planning and Preparation 349 Informatics Tools to Support Communication and Dissemination 350 Using Feedback to Improve Responses and Promote Readiness 351 Summary 353 References 355

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18 Telenursing and Remote Access Telehealth 359 Original contribution by Audrey Kinsella, Kathleen Albright, Sheldon Prial, and Schuyler F. Hoss; revised by Kathleen Mastrian and Dee McGonigle Introduction 359 The Foundation of Knowledge Model and Home Telehealth 359 Nursing Aspects of Telehealth 361 History of Telehealth 362 Driving Forces for Telehealth 363 Telehealth Care 366 Telenursing 370 Telehealth Patient Populations 372 Tools of Home Telehealth 375 Home Telehealth Software 378 Home Telehealth Practice and Protocols 380 Legal, Ethical, and Regulatory Issues 381 The Patient’s Role in Telehealth 382 Telehealth Research 383 Evolving Telehealth Models 385 Parting Thoughts for the Future and a View Toward What the Future Holds 386 Summary 387 References 388

SECTION V: EDUCATION APPLICATIONS OF NURSING INFORMATICS 393

19 Nursing Informatics and Nursing Education 397 Heather E. McKinney, Sylvia DeSantis, Kathleen Mastrian, and Dee McGonigle Introduction: Nursing Education and the Foundation of Knowledge Model 397 Knowledge Acquisition and Sharing 398 Evolution of Learning Management Systems 398 Delivery Modalities 400 Technology Tools Supporting Education 405 Internet-Based Tools 413 Promoting Active and Collaborative Learning 420 Knowledge Dissemination and Sharing 423 Exploring Information Fair Use and Copyright Restrictions 426 The Future 427 Summary 428 References 429

20 Simulation, Game Mechanics, and Virtual Worlds in Nursing Education 433 Dee McGonigle, Kathleen Mastrian, Brett Bixler, and Nickolaus Miehl Introduction 433 Simulation in Nursing Informatics Education 434 Nursing Informatics Competencies in Nursing Education 436 A Case for Simulation in Nursing Informatics Education and Nursing Education 437

Contents xiii

Incorporating EHRs into the Learning Environment 441 Challenges and Opportunities 445 The Future of Simulation in Nursing Informatics Education 445 Game Mechanics and Virtual World Simulation for Nursing Education 446 Game Mechanics and Educational Games 448 Virtual Worlds in Education 450 Choosing Among Simulations, Educational Games, and Virtual Worlds 451 The Future of Simulations, Games, and Virtual Worlds in Nursing Education 452 Summary 453 References 454

SECTION VI: RESEARCH APPLICATIONS OF NURSING INFORMATICS 459

21 Nursing Research: Data Collection, Processing, and Analysis 463 Heather E. McKinney, Sylvia DeSantis, Kathleen Mastrian, and Dee McGonigle Introduction: Nursing Research and the Foundation of Knowledge Model 463 Knowledge Generation Through Nursing Research 464 Acquiring Previously Gained Knowledge Through Internet and Library Holdings 466 Fair Use of Information and Sharing 468 Informatics Tools for Collecting Data and Storage of Information 469 Tools for Processing Data and Data Analysis 471 The Future 473 Summary 473 References 474

22 Data Mining as a Research Tool 477 Dee McGonigle and Kathleen Mastrian Introduction: Big Data, Data Mining, and Knowledge Discovery 477 KDD and Research 481 Data Mining Concepts 482 Data Mining Techniques 483 Data Mining Models 486 Benefits of KDD 489 Data Mining and Electronic Health Records 490 Ethics of Data Mining 491 Summary 491 References 492

23 Translational Research: Generating Evidence for Practice 495 Jennifer Bredemeyer, Ida Androwich, Dee McGonigle, and Kathleen Mastrian Introduction 495 Clarification of Terms 495 History of Evidence-Based Practice 498 Evidence 498 Bridging the Gap Between Research and Practice 499 Barriers to and Facilitators of Evidence-Based Practice 500 The Role of Informatics 500

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Developing EBP Guidelines 503 Meta-Analysis and Generation of Knowledge 504 The Future 505 Summary 506 References 507

24 Bioinformatics, Biomedical Informatics, and Computational Biology 511 Dee McGonigle and Kathleen Mastrian Introduction 511 Bioinformatics, Biomedical Informatics, and Computational Biology Defined 511 Why Are Bioinformatics and Biomedical Informatics So Important? 514 What Does the Future Hold? 516 Summary 518 References 519

SECTION VII: IMAGINING THE FUTURE OF NURSING INFORMATICS 521

25 The Art of Caring in Technology-Laden Environments 525 Kathleen Mastrian and Dee McGonigle Introduction 525 Caring Theories 526 Presence 529 Strategies for Enhancing Caring Presence 530 Reflective Practice 533 Summary 534 References 535

26 Nursing Informatics and the Foundation of Knowledge 537 Dee McGonigle and Kathleen Mastrian Introduction 537 Foundation of Knowledge Revisited 537 The Nature of Knowledge 539 Knowledge Use in Practice 541 Characteristics of Knowledge Workers 544 Knowledge Management in Organizations 545 Managing Knowledge Across Disciplines 547 The Learning Healthcare System 548 Summary 550 References 551

Abbreviations 553 Glossary 556 Index 586

Contents xv

Preface

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 Infor- matics (OJNI), which Dee McGonigle cofounded with Renee Eggers. 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 pre- sented 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 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.

In this fourth edition, we reviewed and updated all of the chapters based on technological advance- ments and changes to the healthcare arena, including reimbursement mechanisms for services. We have pared this edition down to 26 chapters from the previous edition’s 29; one chapter each was deleted from Sections II, V, and VII. Section I includes updates to the same five chapters on the building blocks of nurs- ing informatics, with extensive changes to Chapter 3, Computer Science and the Foundation of Knowledge Model. To improve flow, we combined content. In Section II, the previous four chapters were narrowed to three. New Chapters 6, History and Evolution of Nursing Informatics and 7, Nursing Informatics as

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a Specialty, were developed and appropriate material from previous Chapters 6, 7, and 8 were assimi- lated. This section ends with an updated Chapter 8, Legislative Aspects of Nursing Informatics: HITECH and HIPAA (formerly Chapter 9). Section III contains the same five chapters, although all were updated and Chapter 13, Workflow and Beyond Meaningful Use (formerly Chapter 14) now reflects the payment models and reimbursement issues that we are adjusting to after meaningful use has gone away. Section IV contains the same five chapters with updated content and some name changes to reflect the current status of informatics and healthcare. Chapter 15 was renamed to Informatics Tools to Promote Patient Safety and Quality Outcomes, and Chapter 16 has been changed to Patient Engagement and Connected Health. Section V went from three chapters to two chapters: Chapter 19 (formerly Chapter 20) was updated, while the new Chapter 20, Simulation, Game Mechanics, and Virtual Worlds in Nursing Education, had content from former Chapters 21 and 22 integrated during its development. Section VI was renamed to Research Applications of Nursing Informatics. It still has the same four chapters, which have been updated, but the first chapter in this section, 21, was renamed to reflect nursing research; its new name is Nursing Research: Data Collection, Processing, and Analysis. Section VII went from three chapters to two chapters. Because emerging technologies are discussed throughout the text, the chapter focusing specifically on that was removed. The two chapters that remain are Chapter 25, The Art of Caring in Technology-Laden Environ- ments, and the new Chapter 26, Nursing Informatics and Knowledge Management. In addition, the ancil- lary materials have been updated and enhanced to include competency-based self-assessments and mapping the content to the current NI standards.

We believe that this text provides a comprehensive elucidation of this exciting field. Its theoretical under- pinning 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 inter- acting with our environment and being inundated with information and knowledge. We experience our envi- ronment 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 re- structure 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 re-exploring 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.

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

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

Preface xvii

• Section III, Nursing Informatics Administrative Applications: Precare and Care Support, covers important functions of administrative applications of NI.

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

• Section V, Education Applications of Nursing Informatics, presents subject matter on how informat- ics supports nursing education.

• Section VI, Research Applications of Nursing Informatics, covers informatics tools to support nursing research, including data mining and bioinformatics.

• Section VII, Imagining the Future of Nursing Informatics, focuses on the future of NI, emphasizes the need to preserve caring functions in technology-laden environments, and reviews the relationship of nursing informatics to 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 acqui- sition, 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 ground- work 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 princi- ples so that they efficiently and effectively function as current and future nursing professionals to enhance the nursing profession and improve the quality of health care. The overall vision, framework, and peda- gogy 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.

xviii Preface

Acknowledgments

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, Emma Huggard, and Christina Freitas, all of whom fielded our questions and concerns in a very professional, respectful, and timely manner.

Dee acknowledges the undying love, support, patience, and continued encouragement of her best friend and husband, Craig, and her son, Craig, who has 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, espe- cially Renee.

Kathy acknowledges the loving support of her family: husband Chip; children Ben and Alicia; sisters Carol and Sue; and parents Robert and Rosalie Garver. She dedicates her work on this edition to her dad, Robert, who died September 17, 2016. Kathy also acknowledges those friends who understand the impor- tance of validation, especially Katie, Lisa, Kathy, Maureen, Anne, Barbara, and Sally.

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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!

Authors’ Note

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Contributors

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

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

Nedra Farcus, MSN, RN Retired from 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

xxi

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 Oregon Health Sciences University Monmouth, OR

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

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

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

xxii Contributors

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. Nurs- ing 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. Regard- less 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 antici- pating 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 nurs- ing 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.

2 seCtIoN I Building Blocks of Nursing Informatics

To prepare for these innovations, the reader must understand fundamental infor- mation and computer concepts, covered in the Introduction to Information, Informa- tion Science, and Information Systems and Computer Science and the Foundation of Knowledge Model chapters, respectively. Information science deals with the in- terchange (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 man- age 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 knowl- edge 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 associ- ated 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 sys- tems, 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

seCtIoN I Building Blocks of Nursing Informatics 3

data necessary, processes these into information, and generates and disseminates the resulting knowledge. Through this dynamic exchange, which includes feedback, indi- viduals continue the interaction and use of these sciences to input or acquire, process, and output or disseminate generated knowledge. Humans experience their environ- ment 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 and process feedback on their new knowledge of the building blocks of NI.

4 seCtIoN I Building Blocks of Nursing Informatics

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

KA - Knowledge acquisition KD - Knowledge dissemination KG - Knowledge generation KP - Knowledge processing

Information

Information

Information Information

Data

Data

Bytes Bytes

Bytes

Bits

Bits Data

Bits

Bytes

Bytes Bytes Bits

Bits Data Information

Feedback

KA KP

KD

KG

Feedback

seCtIoN I Building Blocks of Nursing Informatics 5

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

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.

objectives

Introduction Nursing informatics has been traditionally defined as a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. This chapter focuses on nursing science as one of the building blocks of nurs- ing informatics. As depicted in Figure 1-1, the traditional definition of nursing

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

Figure 1-1 Building Blocks of Nursing Informatics

Nursing Informatics

Nursing Science

Computer Science

Cognitive Science

Information Science

7

CHAPteR 1

informatics is extended to include cognitive science. 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 hos- pital 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 immedi- ate 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 tech- nology (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 nurs- ing 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, psy- chology, and chemistry, as he determined the patient’s immediate needs. Informa- tion 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 profes- sional 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 (2016) defines nursing in this way: “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individu- als, families, groups, communities, and populations” (para. 1). Thus the focus of nursing is on human responses to actual or potential health problems and advo- cacy for various clients. These human responses are varied and may change over

8 CHAPteR 1 Nursing Science and the Foundation of Knowledge

time in a single case. Nurses must possess the technical skills to manage equip- ment and perform procedures, the interpersonal skills to interact appropriately with people, and the cognitive skills to observe, recognize, and collect data; ana- lyze 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 ser- vices 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.