Data Information Knowledge Wisdom in Nursing Informatics

ANS1115 January 22, 2016 0:7 Advances in Nursing Science Vol. 39, No. 1, pp. E1–E18 c 2016 Wolters Kluwer Health, Inc. All rights reserved. Copyright  The Evolution of DataInformation-Knowledge-Wisdom in Nursing Informatics Charlene Ronquillo, MSN, RN; Leanne M. Currie, PhD, RN; Paddy Rodney, PhD, RN The data-information-knowledge-wisdom (DIKW) model has been widely adopted in nursing informatics. In this article, we examine the evolution of DIKW in nursing informatics while incorporating critiques from other disciplines. This includes examination of assumptions of linearity and hierarchy and an exploration of the implicit philosophical grounding of the model. Two guiding questions are considered: (1) Does DIKW serve clinical information systems, nurses, or both? and (2) What level of theory does DIKW occupy? The DIKW model has been valuable in advancing the independent field of nursing informatics. We offer that if the model is to continue to move forward, its role and functions must be explicitly addressed. Key words: information science, nursing informatics, nursing philosophy, nursing theory If we cannot name it, we cannot control it, finance it, teach it, research it, or put it into public policy. Norma Lang (in Clark and Lang)1 M AKING NURSING WORK VISIBLE has been a historical challenge that the profession continues to contend with. Early research sought to distinguish nursing work as distinct from other professions, informed by its own bodies of knowledge. Meanwhile, contemporary challenges include developing quantifiable ways of representing nursing work, developing methods to capture aspects of nursing that “can’t be quantified,” identifying nursing-sensitive outcomes, and issues related to the move toward digitized health Author Affiliation: School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada. The authors have no conflicts of interest to declare. Correspondence: Charlene Ronquillo, MSN, RN, School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada (cronquillo@alumni.ubc.ca). DOI: 10.1097/ANS.0000000000000107 systems.

Operationalizing ways of making nursing work visible, valued, and “counted” in health systems, facilitated by the use of information technology has been a foundational driving force in the field of nursing informatics.1 Seminal work by Graves and Corcoran2 was aimed to outline the scope and define the field of nursing informatics and to delineate and define nursing work as related to information technology. A foundational conceptual approach described by Graves and Corcoran as central to nursing informatics is the data, information, knowledge, wisdom (DIKW) framework, which continues to play a central role in the field today. By outlining the definitions, roles, and interrelationships within DIKW, the framework has undoubtedly been instrumental in moving and informing the field toward the goal of making nursing work visible. Interest in DIKW has been sustained, and its evolution has continued over the decades, illustrated by the various iterations and revisions of the model to meet the needs of contemporary nursing3-5 and the continued efforts and approaches to better understand the framework and explore its application.6 E1 Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. ANS1115 January 22, 2016 E2 ADVANCES 0:7 IN NURSING SCIENCE/JANUARY–MARCH 2016 The aims of this article are (1) to examine the theoretical foundations of the DIKW model through deconstruction of some implicit claims within the model and (2) to step back to examine potential reasons why DIKW has come to be depicted in the way that it has. To achieve our aims, we have used 2 approaches. First, we conducted a literature review, focusing in particular on other fields of study where DIKW has been taken up. Second, we examined syntheses of some main critiques of DIKW, particularly in relation to the way that DIKW has been taken up in nursing. This second approach led to a philosophical exploration of the implicit assumptions that the concepts within DIKW are founded on and interpretations of the model’s presumed purpose and theoretical application. Our philosophical exploration includes some reflections on the implications for nursing’s obligations to diverse populations and interdisciplinarity.

DIKW IN NURSING INFORMATICS Graves and Corcoran’s2 seminal paper, “The Study of Nursing Informatics,” established nursing informatics as a field of scholarly inquiry in the late 1980s and early 1990s.6 They describe nursing informatics as “a combination of computer science, information science and nursing science designed to assist in the management and processing of nursing data, information and knowledge to support the practice of nursing and the delivery of nursing care.”2(p227) Nursing informatics captures the juncture of these 3 core sciences; the focus on nursing science differentiates nursing informatics from other specialties, such as biomedical informatics.5 Graves and Corcoran’s article is acknowledged as instrumental in shifting the discourse in nursing informatics from being concerned with technology itself to the purpose of technology and concepts related to information science in the context of nursing.7 On the foundations of nursing informatics, Graves and Corcoran explained: This framework for nursing informatics relies on a taxonomy and definition of the central concepts of data, information and knowledge put forward by Blum (1986), who defines data as discrete entities that are described objectively without interpretation, information as data that are interpreted, organized or structured and knowledge as information that has been synthesized so that interrelationships are identified and formalized.2 (See Figure 1 for Graves and Corcoran’s depiction of data-information-knowledge [DIK].) In the field of nursing informatics, Nelson and Joos are cited as the first to add the concept of wisdom in 1989, described as the “appropriate use of knowledge in managing or solving human problems . . . it [wisdom] is knowing when and how to use knowledge to manage a patient need or problem.”8 The American Nurses Association’s Scope and Standards for Nursing Informatics adopted the inclusion of wisdom to the DIK framework in 2008, arguing that it “reflects today’s emerging mandate for evidence-based practice and decision support resources for the knowledge worker.”9(p855) The conceptualization of DIK and the addition of wisdom are important developments in the attempts to better articulate and make nursing work visible, particularly in relation to the digitization of health systems. DIKW has been instrumental in expanding the scope of practice in nursing informatics to be “no longer fully defined by the functionality of a computer and the types of applications processed by a computer . . . [but is] now defined by the goals of nursing and nurse-computer interactions in achieving these goals.”4(p27) Through these Figure 1. Conceptual framework for the study of nursing informatics (as proposed by Graves and Corcoran2 ). Reprinted with permission. Data Information Knowledge Wisdom in Nursing Informatics

Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. ANS1115 January 22, 2016 0:7 The Evolution of DIKW in Nursing Informatics developments, DIKW has become a canonical framework in nursing informatics. ORIGINS OF DIK AND DIKW Graves and Corcoran adopted the DIK framework from Blum’s 1986 book, where he suggested that medical computing had 4 phases: (1) 1955-1965: experimentation and orientation; (2) 1965-1975: data processing success; (3) 1975-1985: information processing success; and (4) 1985-[1986 and future]: knowledge processing success. He further described 3 types of applications: (1) data-oriented applications, such as systems designed for business data, clinical laboratory data, patient monitoring, diagnostic systems, and imaging (eg, computed tomographic scan); (2) information-oriented applications including clinical information systems that can provide administrative support (eg, reduce errors) and medical decision support (eg, alerts and reminders to support clinical decision making); and (3) knowledgeoriented applications such as bibliographic databases, and artificial intelligence systems (ie, systems that have the ability to apply “smart reasoning”).10 In his book, Blum acknowledges that systems at the time had difficulty codifying “the most elementary body of knowledge—common sense.” It is unclear where the model posed by Blum originated.

Desrosières11 suggests that the origins of DIK derives from the 17th-century ideas of taxonomies of nature that later matured into classification of populations toward “the construction and stabilization of social order . . . , the production of a common language allowing individual acts to be coordinated and . . . [for systems to be able to be] capable of orientation and triggering action.” Given the rapidly increasing proliferation of complex work related to nursing informatics happening nationally and internationally, we believe that an approach such as DIK can provide a common language and coordination of individuals from various disciplines (eg, nursing, computer sci- E3 ence, information science, medicine) is most welcome. The addition of “wisdom” to the DIK model has largely been attributed to Ackoff’s 1989 address to the Society for General Systems. In this address, Ackoff12 accentuates the interplay between knowledge and wisdom, and although he does not present a graphical depiction of the ideas, he clearly suggests a hierarchical format wherein the concepts of DIKW build one upon the other. THE EVOLUTION OF DIKW IN NURSING INFORMATICS Since it was first introduced in nursing 26 years ago, the evolution and refinement of DIK and then DIKW have been ongoing, with the most recent changes to the model made in 2013.4 The various revisions of DIKW have aimed to address the limitations of the original model by providing further details of the relationships and interactions between the concepts of DIKW. Figures 2-4 show the evolution of visual depiction of the DIKW model. The relevance of the DIKW framework in nursing informatics is illustrated by the ongoing adaptation and extension of the framework to underpin research studies. For example, Gee et al13 suggest an extension of the DIKW framework by integrating clinicians and the e-patient into the model. This is framed as the DIKW Collaborative Model, where the e-patient, or electronic patient, is one who uses information resources on the Internet to self-manage his or her own health. Gee et al13 posit that the crucial interaction between the clinician and the e-patient can be supported by the DIKW framework and suggest that data could be coproduced by patients and clinicians. They note that the “e-patient could educate the health care team on what data mean in their life context . . . and together they would create plans . . . using collective wisdom from support groups, social networking sites, blogs, databases and research”13 (see Figure 5).

Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. ANS1115 January 22, 2016 E4 ADVANCES 0:7 IN NURSING SCIENCE/JANUARY–MARCH 2016 Figure 2. Nelson DIKW, version 1 (2001), is the original visual depiction of the DIKW theoretical model as referred to in nursing informatics. DIKW indicates data-information-knowledge-wisdom. Copyright ownership by Ramona Nelson, Ramona Nelson Consulting. All rights reserved. Reprinted with permission. Figure 3. Nelson DIKW, version 2 (2008), adds constant flux, suggesting the possibility of bidirectional movement across the DIKW continuum. DIKW indicates data-information-knowledge-wisdom. Copyright ownership by Ramona Nelson, Ramona Nelson Consulting. All rights reserved. Reprinted with permission. Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. ANS1115 January 22, 2016 0:7 The Evolution of DIKW in Nursing Informatics E5 knowledge is conceptualized as tacit or explicit, and these are underpinned by wisdom (see Figure 7). Most recently, Matney and colleagues15,16 have proposed a theory of Wisdom-in-Action. In this model, the concept of data has been subsumed into the context of electronic health records and the concepts of information, knowledge, and wisdom are clearly delineated as interacting with each other (see Matney15 for visual representation). Data Information Knowledge Wisdom in Nursing Informatics

CRITICISMS OF THE DIKW MODEL Figure 4. Nelson DIKW, version 3 (2013), maintains bidirectional movement with constant flux and is revised to suggest greater interaction, overlap, and interrelationships between concepts, as well as the possibility of moving back and forth between constituent concepts. DIKW indicates data-informationknowledge-wisdom. Copyright ownership by Ramona Nelson, Ramona Nelson Consulting. All rights reserved. Reprinted with permission. Looman et al14 used the DIKW framework to inform their study of care coordination in the context of telehealth for families. In their conceptual model, the DIKW constructs are depicted as underpinning a model of care coordination; data are conceptualized as historic or current and as subjective or objective, and Although various revisions of DIKW in nursing informatics illustrate continued attempts at better delineating and understanding the model and its application, critiques of DIKW in other fields have been more explicit, systematic, and nuanced and have sought to challenge the model. The following sections consider perspectives of DIKW from nursing informatics in light of criticisms of DIKW from the fields of information science, knowledge management, geography, management information systems, and library information sciences. The critiques we have synthesized from our literature review focus on the limitations of DIKW’s hierarchical structure and epistemological narrowness in understanding the concepts of DIKW. LINEARITY AND HIERARCHY IN DIKW Figure 5. The DIKW model as depicted by Gee et al.13 DIKW indicates data-information-knowledge-wisdom. Reprinted with permission. Published critiques of DIKW outside of nursing focus largely around the uncritical acceptance of DIKW and the implications of accepting it at face value, as well as the inability to operationalize the model.17-21 As we show in what follows, these critiques coalesce around concerns about the linearity and hierarchy implicit in how the model is taken up. In the field of information science, DIKW is referred to as the knowledge/information hierarchy or information/knowledge pyramid and is visually represented in a manner Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. ANS1115 January 22, 2016 E6 ADVANCES 0:7 IN NURSING SCIENCE/JANUARY–MARCH 2016 Figure 6. A side-by-side comparisons of the DIKW models as depicted in nursing informatics (left) and computer science, management information systems, and library sciences (right) illustrate the common attributes of DIKW visualizations: consolidation of power, linear and positive growth, and an implicit assignment of value to concepts (ie, “building” toward to the pinnacle of wisdom, which is the most important). DIKW indicates data-informationknowledge-wisdom. different from that of DIKW in nursing informatics (see Figure 6). Data are described to be most abundant, forming the foundational level upon which the remaining concepts build on, with the decreasing width of the triangle at each level suggesting decreased abundance.22 Concurrently, movement up the triangle suggests increasing power to support the ability to take appropriate action.22 In information science, reference to DIKW as a knowledge hierarchy alludes to the assignment of value to concepts in the model. Specifically, concepts are characterized by dominance or importance.22 Depicting DIKW as a pyramid is suggested as a means of proposing a consolidation of power in the upper levels from the lower levels.20,22 In nursing informatics, DIKW is not visualized in the same way. However, a side-by-side comparison of visualizations illustrates similar features of the models (see Figure 6). Data Information Knowledge Wisdom in Nursing Informatics

Notably, the visualization of DIKW in nursing informatics depicts a similar allusion to linear and “positive” growth, a hierarchy among concepts, and a consolidation of effect in the movement from data to wisdom. In the field of geography, Poore and Chrisman outline the problematic nature of this depiction of DIKW, asserting that “the information pyramid embodies and normalizes theories of power, reflecting the hierarchical social structures of the old industrial economy.”23(p511) They suggest that the valuing of concepts in DIKW has the potential to spill over and unintentionally be seen to apply to individuals and professions, “with manual workers on the bottom and knowledge workers and bosses on the top.”23(p511) Furthermore, depicting knowledge and wisdom as higher up in the traditional nursing informatics depiction of DIKW suggests that they are more valuable than data and information. Indeed, a premise of DIKW is the movement toward wisdom as the ultimate goal. Frické suggests that this depiction of DIKW is reminiscent of “inductivist growth-byaccretion model of science” that has largely been abandoned—thanks to the work of Popper and Kuhn demonstrating the fallible and value-laden nature of knowledge—in favor of accepting that “even the most cherished of ‘pure observational facts’ is open to the possibility of revision.”18(p6) Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. ANS1115 January 22, 2016 0:7 The Evolution of DIKW in Nursing Informatics E7 Figure 7. The DIKW model as depicted by Looman et al.14 DIKW indicates data-information-knowledge-wisdom. Reprinted with permission. The notion of data eventually consolidating into wisdom is problematic in a number of ways. For one, it reflects outdated ideals related to how science develops, as mentioned previously. Second, the question arises of just how the movement from data to wisdom takes place—what causes the movement? Is there an innate inertia that moves, consolidates, and transforms data across the other DIKW concepts to reach the pinnacle of wisdom? In the field of medical informatics, Georgiou critiqued the underlying assumptions of the informatics model, stating that “It [the informatics model] is . . . founded on some questionable assumptions, particularly if the process of data/information/knowledge is viewed lin- early, whereby the mere capture of data on one side of the spectrum can lead seamlessly to information and then knowledge. In reality there are a number of interrelated activities involved in the generation of information.24(p128) Although these criticisms draw from the pyramid structure, the similar hierarchical structure alluded to in the nursing informatics model of DIKW warrants concurrent consideration of this criticism. Another salient critique of DIKW relates to the linear movement between concepts within the model. Data Information Knowledge Wisdom in Nursing Informatics

These are, arguably, shaped by the values attributed to each of the concepts of DIKW. The depiction of DIKW suggesting linear, unidirectional Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. ANS1115 January 22, 2016 E8 ADVANCES 0:7 IN NURSING SCIENCE/JANUARY–MARCH 2016 movement between concepts has been challenged. Various authors have highlighted the lack of consensus and varying views on how DIK is defined, bounded, and created, positing instead the possibility for bidirectional movement between concepts as necessary. … Data Information Knowledge Wisdom in Nursing Informatics