Philosophical Approaches to the Nursing Informatics Data- Information-Knowledge-Wisdom Framework

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Advances in Nursing Science Vol. 34, No. 1, pp. 6–18 Copyright c 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Philosophical Approaches to the Nursing Informatics Data- Information-Knowledge-Wisdom Framework

Susan Matney, MSN, RN, FAAN; Philip J. Brewster, PhD; Katherine A. Sward, PhD, RN; Kristin G. Cloyes, PhD, RN; Nancy Staggers, PhD, RN, FAAN

Although informatics is an important area of nursing inquiry and practice, few scholars have articulated the philosophical foundations of the field or how these translate into practice including the often-cited data, information, knowledge, and wisdom (DIKW) framework. Data, information, and knowledge, often approached through postpositivism, can be exhibited in computer systems. Wisdom aligns with constructivist epistemological perspectives such as Gadamerian hermeneutics. Computer systems can support wisdom development. Wisdom is an important element of the DIKW framework and adds value to the role of nursing informaticists and nursing science. Key words: constructivism, hermeneutics, information management, knowledge, nursing informatics, nursing, nursing research, objectivism, philosophy, postpositivism, qualitative research

Where is the wisdom we have lost in knowledge? throughout the international NI community. Where is the knowledge we have lost in informa- In 2008, the American Nurses Association tion? (ANA) revised the Scope and Standards for Thomas Stearns Eliot1 Nursing Informatics to include an additional concept, wisdom, in the definition of nurs- ARLY definitions of nursing informatics 2 2 ing informatics. Data, information, knowl- E(NI) varied but soon coalesced around edge, and wisdom (DIKW) provide a founda- 3 Graves and Corcoran’s seminal article outlin- tional framework for NI and the framework is ing data, information, and knowledge as foun- useful for the broader nursing community as dational concepts for the specialty. Their con- well, providing a basis for linking theory and ceptual framework has been widely accepted practice. The philosophical foundations of this widely accepted framework have not been well described. The recognition of Graves and Author Afﬁliations: Office of the Associate Vice President for Health Sciences Information Corcoran’s work and its worldwide adoption Technology (Ms Matney), College of Nursing by the nursing informatics community, cou- (Ms Matney and Drs Sward, Cloyes, and Staggers), pled with the more recent addition of the con- Department of Biomedical Informatics (Dr Brewster, Sward, and Staggers), University of Utah, Salt Lake cept of wisdom, merit philosophical inquiry City; School of Nursing, University of Maryland, and clarification. Therefore, we describe the Baltimore (Dr Staggers). concepts of the data, information, knowl- We thank Dr Maeona K. Kramer for her review and edge, and wisdom (DIKW) framework and insightful critique of this article. how they are used in nursing and NI. We ex- Correspondence: Susan Matney, MSN, RN, FAAN, 1148 North Alice Lane, Farmington, UT 84025 (susan. plain two philosophical approaches, postpos- [email protected]). itivism and the hermeneutics of Hans-Georg 6

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Figure 1. DIWK framework. Reprinted with permission from Nelson.17

Gadamer that collectively provide an episte- upon each other, growing in scope and mean- mological basis for understanding the DIKW ing as they become increasingly abstract and framework. We examine how each approach sophisticated.2 ‘Fuzzy’ or overlapping bound- contributes conceptual clarity and structure aries exist at the juncture between each of the for the DIKW framework as a foundation for concepts. As a prelude to the philosophical nursing informatics. We provide NI and nurs- discussion, the following section describes ing examples of these perspectives, and dis- each DIKW concept in more detail. cuss how DIKW can be useful in linking theory with practice. DATA DIKW FRAMEWORK IN NURSING Data are the smallest units in the DIKW Informatics has been identified as one of framework. They are typically understood the core competencies for nurses at all levels as symbols that represent objects, events, of practice, not just for informatics nurse and their properties. Data come in many specialists.2,4 Data, information, knowledge, forms such as numbers, words, sentences, or and wisdom are considered overarching pictures—they can be anything given, no mat- concepts (metastructures) supporting all of ter what the origin or form.6 Data have been nursing and informatics practice. The DIKW explained as the products of observation,7 dis- concepts, often described as a hierarchy, crete facts with a minimum of interpretation.3 originated in computer and information Thus, a single piece of data (a datum) has sciences, in particular, in the subspecialty little or no meaning in isolation. Data are of knowledge management.5 Figure 1 is the the form most often stored within patient most current model adopted by nursing in- records, and are used as a basis for further rea- formatics, illustrating how the concepts build soning, calculation, or discussion.

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INFORMATION may call this “background” knowledge. Ex- plicit knowledge, in contrast, can be gener- Information may be thought of as “data ated and formalized, and is more amenable to plus meaning.” It can be derived by process- encoding and transmitting in a formal man- ing data.3 Information represents the facts and ner. Explicit knowledge is what knowledge ideas that are available to be known within management systems (such as computer deci- a certain context.8 When data are put into a sion support systems) seek to capture, codify, context and combined within a structure, in- store, transfer, and share. formation emerges.9 Like the transformation of data to infor- Data and information are not discrete bits; mation, the transformation of information to rather, there is a continuum of progressively knowledge in nursing and information sys- increased meaning and value.10 To describe tems can be conceptualized as a continuum an example of data becoming more meaning- of increasing understanding.10 Knowledge is ful information, consider the number “110.” derived by discovering patterns and relation- The number has little meaning without con- ships between types of information. text. When developed into a name-value pair, Consider the previous example of a patient such as “heart rate = 110” (where heart rate with a heart rate of 110 beats per minute. If is the name, and 110 beats per minute is we combine this with additional information the value), a meaning begins to emerge. The such as: this is a 70-year-old man with pneu- phrase “a heart rate of 110”increases in mean- monia, his blood pressure is 80/60 mm Hg ing when we know that the context is an older and decreasing steadily from previous values, adult. Data and information not only repre- his temperature is 101oF,his respiratory rate is sent physical observations, but may also rep- 30, his urine output has totaled 60 mL in the resent abstract concepts such as depression, past 4 hours, and his skin is dry to the touch— pain, spirituality, or psychosocial care.11 then based on known physiologic patterns Information answers questions that begin nurses will conclude that this person is ex- with basic words such as who, what, where, hibiting signs of dehydration caused by his when, and how many. Information may be or- fever and pneumonia, and he needs increased ganized in ways that serve the interests of a fluid intake. This exemplifies nursing knowl- discipline12 and in practice, health informa- edge. Similarly, knowledge may be exhibited tion is organized in a way unique to the prac- when a nurse formulates a nursing diagnosis, tice of nursing. such as spiritual distress, and identifies the potential interventions such as spiritual care or a clergy referral that could lead to a positive KNOWLEDGE outcome.11

Just as data can be transformed into meaningful information, so too can information be WISDOM transformed into knowledge. Knowledge is information that has been synthesized so that The ANA defines wisdom as the appropri- relationships are identified and formalized.3 ate use of knowledge to manage and solve hu- Knowledge answers questions that begin man problems.2 Beyond that, wisdom implies with “how”and “why.” a form of ethics, that is, knowing why things There are many types of knowledge.13 Two should or should not be done in practice.15 types are described within the field of knowl- It is not a fixed entity, but rather a recip- edge management: tacit and explicit. Tacit rocal, action-oriented process.16 Wisdom in- knowledge is difficult to summarize and com- volves recognizing what is most important, municate to others.14 It is personal, context- by making distinctions among alternatives. specific, and therefore hard to formalize.9 We It comprises the application of experience,

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intelligence, creativity, and knowledge, as me- to frame and illuminate how the DIKW diated by values, toward the achievement of functions as the basis of informatics inquiry a common good.17 Benner18 bases the un- and practice. derstanding of wisdom in nursing on clinical judgment and a thinking-in-action approach that encompasses intuition, emotions, and the DEFINITIONS senses. Yet, each of these extant definitions does not fully capture the complexity or so- The definitions and usages of philosophical phistication of the concept. terms have evolved over time, and nuances of There is an increased level of critical think- those definitions remain the subject of philo- ing at each level of the DIKW framework. Al- sophical debate. Many of the terms remain though the progression from knowledge to broadly defined and have fuzzy boundaries.21 wisdom is not as straightforward as the path Although acknowledging other definitions ex- among the other concepts, wisdom builds on ist for these terms, and that other terms may and uses knowledge. The difference between fit these definitions, we begin with an ex- knowledge and wisdom is like the difference plication of philosophical terms used here between memorizing and understanding— and the meaning we intend when using these there is a process of internalization. terms. This explication provides the assump- To continue our previous examples, wis- tions and foundation for the later discussion. dom is displayed when the nurse chooses Epistemology is the study of the na- a specific, tailored means of providing fluid ture of knowledge. It is the philosophical to the elderly patient with pneumonia. The grounding for deciding what kinds of knowl- nurse who chooses a form of spiritual care, edge are possible, “how we know what we based perhaps on the preferences and in- know,”21(p4) and how knowledge links with clinations of the patient, is also displaying related concepts.21,22 Following Crotty,21 2 wisdom. common epistemological perspectives are objectivism and constructivism. Objectivism is the epistemological per- PHILOSOPHICAL APPROACHES spective that things exist and have intrinsic meaning independent of human There are different—at first glance even experience.21 It is the perspective of the contradictory—philosophical approaches world as an objective reality that can be dis- that inform and provide conceptual struc- covered by an observer who is distinct from ture for the DIKW framework. Nursing has the thing observed.21,22 We understand post- long recognized that there can be valuable positivism as an example of this perspective. contributions from theories emerging from Postpositivism in this article encompasses different paradigms and epistemologies.19 At the basic assumptions of objectivism (such the intersection of philosophical paradigms as intrinsic reality that can be discovered, and the exploration of the DIKW frame- researcher objectivity, and generalizability of work is the question: What is meant by findings) but acknowledges that scientific “knowledge” and how does knowledge, in statements are tentative and contain a level turn, support “wisdom?” That is, what is of uncertainty and error.21,22 We chose this the appropriate application of knowledge to example because much of the nursing infor- form wisdom? We argue that 2 distinct yet matics literature has been approached from integrated epistemological approaches, the the perspective of postpositivism. objectivist approach of postpositivism and Constructivism is the epistemological per- the interpretive approach of Gadamerian spective stating that meaning comes into ex- hermeneutics (especially what Gadamer istence through engagement with the world. termed practical philosophy),20 combine This perspective suggests that meaning is

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constructed as an interaction between hu- marily in the objectivist epistemology are mans and the world around them.21,22 what we mean when we use the term We use Gadamerian hermeneutics as an postpositivism.21,22 example of an approach arising from this Unlike the certainty and claims of abso- epistemology. Hermeneutics is concerned lute truth within the positivist approach, with interpreting meaning based on a text, Popper,24 a 20th-century philosopher, sug- which may be written or recorded. Although gested that scientific knowledge is proba- there are many varieties of hermeneutics, bilistic and fallibilistic in nature—that there Gadamer’s approach was based on the cen- is a level of uncertainty and error in sci- trality of language and dialogue to understand- ence. He saw scientific knowledge as sub- ing, and that language is bound to history ject to further testing and possible falsifica- and traditions.21,22 We chose this example be- tion at some future date. Popper emphasized cause the focus on language and communica- the influence of background knowledge on tion is compatible with many nursing infor- science, whereas postulating a need for the matics roles and responsibilities. ongoing revision and criticism of scientific assumptions.24 We can see Popper’s influence POSTPOSITIVISM in the methods of research reports today— for example, with statistical findings that in- The objectivist epistemology posits an un- clude confidence levels and levels of signif- derstanding of science in which objects and icance. In information systems, uncertainty phenomena have intrinsic meaning discov- and error are acknowledged in decision sup- erable through observation.22,23 Truth and port systems that employ probabilistic reason- meaning are held to exist within the objects ing methods or “fuzzy logic”algorithms. or phenomena, and are independent of hu- Kuhn25 opened a still wider perspective man consciousness or experience.21 Are- onto the practice of what he called puzzle searcher, or observer, is separate from the solving as representing what science does thing being observed. Detachment in the re- to generate knowledge. Like other postpos- search process is desirable because mean- itivists, Kuhn emphasized that observations ing resides in the objects or phenomena are theory laden; that scientists are never themselves.21,22 completely detached and value free, but that Comte used the term positivism to de- they approach science out of a background scribe a strict application of the objectivist of beliefs and theories.21 We can see Kuhn’s epistemology. Knowledge was viewed as be- influence, for example, when we witness the ing built from unbiased observations (objec- frequent efforts to “upgrade”standardized ter- tive data) through a logical process of induc- minologies in response to changes in health tion to empirically verifiable conclusions.21,22 care practices. In positivism, all that is known must be ex- Postpositivist scientific theory has evolved perienced through the senses. Different ob- and increasingly recognizes the signifi- servers should record the same results, or at cance of context for the understanding of least be able to repeat the same experiments. meaning.21 The postpositivist approach Once the facts have been established, the phe- acknowledges the social aspects of reality, nomenon under observation can be explained accepting that what is “real” includes things by reference to those facts. that cannot be directly observed. Society, Other philosophers have endorsed a less feelings, intelligence, spirituality, pain, and strict form of objectivism, which has evolved similar constructs are assumed to be just as to become the currently prevailing approach real as physical observations, at least to the to “classical” science. Although there have extent that they influence the observable been several schools of thought that followed world.22 Abstract concepts are “observable” positivism, those that remain grounded pri- through surrogate measures that reflect

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the effects of the underlying reality on the nurse determines whether a particular body senses. The rigorously formalized language of knowledge applies to the current patient, of science—whether expressed symbolically at the current time. as digits, codes, concepts, or statistical Early understandings of the DIKW frame- P values—is understood to refer to entities work within nursing informatics were de- that are real and that are described accurately. scribed solely from within the assump- The postpositivistic approach nevertheless tions of objectivist epistemology. Graves and affirms that authentic knowledge comes from Corcoran3 defined data as discrete observa- the truth of facts (data and information), tions described objectively (emphases ours). derived through the use of strict scientific In this regard, we may also note that data en- methods and controls. The facts that “count” tered into an EHR during the course of care are observable and objective.26 Facts repre- are typically referred to as observations. In- senting abstract concepts can be represented formation is formed through aggregation or through observable surrogate measures.11 other replicable procedures. Knowledge is A fundamental assumption of postposi- based on objective data and information, with tivism is that data, information, and knowl- little or no interpretation and minimal inter- edge can be described accurately and can ference from human preconceptions. be created or imputed, stored, shared, and Observations may be used for decision sup- reused. For information and knowledge to port (via the assertion of facts in decision be valid and generalizable, the data must be support systems) and to determine if the cri- “clean,” or virtually independent of context- teria for evidence-based practice have been specific or individual interpretation. This as- met. Individual patient data, evaluated against sumption is exemplified in the use of data- the knowledge that has been encoded in an cleaning operations prior to the permanent evidence-based guideline, can help the nurse storage of data records in a clinical database decide whether to act on the knowledge— or enterprise data warehouse. Use of shared thus illustrating nursing wisdom. Sophisti- definitions for data, and processes to support cated clinical decision support systems can objectivity in collecting data, enable a cer- tailor recommendations to individual patient tain degree of confidence that the meaning of data, helping the nurse decide if a particular data recorded in an electronic health record decision support recommendation is appro- (EHR) can be known and shared. Clinicians priate for this patient, at a particular time. and researchers may conclude that informa- If information is assumed to have mean- tion and knowledge developed from this data ing that can be commonly understood, it fol- will be accurate and can reliably support re- lows logically, then, that nurse informaticists search, clinical nursing practice, and nursing and clinical nurses should collaborate to de- decisions. fine nursing data and ensure that the seman- The progression from data to information tics of “concepts”stored in an EHR are collec- and from information to knowledge, while tively agreed upon. Standardized terminolo- not having discrete boundaries, is internally gies used in nursing include not only physical consistent and may be clearly demonstrated. data, but also abstract concepts such as pain, The idea of evidence-based practice is built coping, or spiritual distress. upon a predominantly objectivist epistemol- Burkhart and Androwich11 discuss mea- ogy, as are many of the practices related to surement of spiritual care using data cap- patient safety and health care quality. Wis- tured in an EHR. This article illustrates a post- dom, defined as appropriate application of positivist approach. The authors emphasize knowledge,2 is also supported in the post- capturing data in such a way that they can positivistic theoretical perspective. Wisdom be aggregated, optimally within structured is demonstrated in nursing decisions and ac- documentation and preferably through quan- tions. Wisdom, then, is illustrated when a titative measures such as Likert-type scales

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(data) using standardized terminology with Gadamer replaces the theoretical concept of agreed upon definitions that are consistently knowing with that of human understanding applied (information). They discuss develop- in practice.27 Gadamer reframes the episte- ing an instrument to consistently measure the mological question of knowledge in the form, abstract concept of spiritual health (knowl- “How is understanding possible?,”28 and an- edge), and discuss appropriate ways to ap- ticipates a response in the form of actively ply the instrument such as during nursing seeking an answer. assessments (wisdom). A philosophical ques- We focus on 2 central themes in Gadamer’s tion (explored further in the article) is: can work. One is the activity of developing under- standardized terms and objective instruments standing in the hermeneutic circle. Second capture the deeper meaning of nurse-patient is what Gadamer called “the universality of care situations? hermeneutics.”29 The hermeneutic circle is a back and forth interplay that makes us aware of the GADAMERIAN HERMENEUTICS “preunderstandings”30 that are essential to our understanding of the world.27 Martin Although the perspective of objectivism Heidegger, one of Gadamer’s philosophical suggests that meaning is contained within teachers, introduced the concept of the objects and phenomena, constructivism is hermeneutic circle to elucidate the idea that the epistemological perspective that meaning understanding is a reciprocal activity. Fur- comes into existence through essentially so- ther elaborating on this concept, Gadamer’s cial engagement. Meaning is constructed as hermeneutic approach was a way of focus- an interaction between humans and the world ing attention on the interpretation of experi- around them.21,22 ence in what he calls the ‘hermeneutic situ- There are many approaches within ation’, as found primarily within dialogue.31 constructivism, including interpretive ap- Gadamerian hermeneutics concentrates on proaches that focus on constructing meaning expanding meaning and shared understand- through language. We will use Gadame- ing through dialogue, whether in a living con- rian hermeneutics as an example of an versation between persons or in the linguis- approach that emerges from this epistemol- tic interplay that takes place between a reader ogy. Traditionally, hermeneutics has been and a text. considered as the art of interpretation and de- The nursing process might be thought of as scribed as a method for understanding texts. a representation of the hermeneutic circle— There are multiple varieties of hermeneutics. from the flow of data collection and prob- Gadamer’s approach is based on the centrality lem identification, through outcome mea- of language and dialogue to understanding, surements, which are a form of data collec- and the premise that language is bound to tion. Documentation that links nursing diag- our history.21,22 noses, interventions, and outcomes, tracks In Gadamerian hermeneutics, subjective those links over time, and is evaluated and re- ways of knowing take on a significant role. vised, also reflects a form of the hermeneutic Gadamer explicitly thematizes the impact of circle. the individual’s background knowledge and In Gadamerian hermeneutics, everyday the ways that preconceptions play an inextri- communication presupposes the historical cable role in human judgment and practice. existence of a language and a collectively Without providing criteria for epistemologi- shared tradition to which it belongs as a cal certainty beyond the assurance that par- medium and repertoire of available meanings. ticipants in a dialogue know the truth of their Meaningfulness is codetermined by language hermeneutic situation implicitly and at every and the context provided by tradition. What moment while being involved in this activity, Gadamer calls tradition can be understood as

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being the knowledge that is effective in the Gadamer’s claim of hermeneutics’ “univer- shared life-world of the participants in dia- sality”in the context of the DIKW framework logue at any given place and time.32 Tradition, supports standardized terminology in that then, is background knowledge, available to there are common human experiences us both tacitly and explicitly. that can be described, there are patterns that This life-world experience is the basis can be known, and language used to com- for what Gadamer called the “universality” municate those patterns. Research based in of philosophical hermeneutics29—the second Gadamerian hermeneutics is needed to help central theme of focus. Universality is the idea identify those patterns. A philosophical ques- that there is a common structure in human tion for nursing informatics is whether it is experience, as given through shared natural possible to communicate the full meaning of languages, which makes understanding possi- language within a standardized terminology. ble. In human life-world contexts, something Meaning and judgment exist in the choice of logically and temporally always precedes our a specific standard terminology to use in a conscious awareness or focused attention. For health record—but how much of that mean- Gadamer, this “something”is language, which ing and judgment can be captured? From the is a type of experience that is tacitly “known” perspective of Gadamerian hermeneutics, to us from our everyday encounters and inter- an unconscious dimension of understanding actions in the world with others. Hermeneu- always exceeds our conceptual grasp. Thus, tic understanding relies on a continuous pro- what language is saying beyond our intended cess of interpretation and translation of mean- meanings can never be completely con- ing within the linguistic world of common hu- trolled or formalized with absolute precision. man experience. The number of contexts-within-contexts- Gadamer underscores the dimensions of within-contexts (and so on...) involved in language and effective history as the horizon even the most common linguistic utter- of human experience.28 The act of interpre- ances is beyond finite human capabilities or tation occurs through what Gadamer calls a understanding. fusion of horizons, which implies that the As opposed to the linear progression from interpreter’s own horizon of expectation is data to knowledge in the empirical per- a limit or boundary informing the act of in- spective, the hermeneutic approach to un- terpretation, as well as that this limit is not derstanding (knowledge) is recursive and permanent, static, or final. The hermeneutic increasingly contextual and personal. The fusion of horizons, in other words, is a dialec- hermeneutic process presupposes that an in- tical process. When new understanding oc- terpreter must be able to understand the curs, it is then possible for a type of learn- cultural and historical horizon of the per- ing to take place or rather, to emerge from a son being understood as well as his or her prior horizon of understanding. This process own cultural biases and limitations.33 Though of learning involves a kind of trusting open- hermeneutic criteria for the reasonableness of ness as a fundamental dimension of the inter- viewpoints and for the justification of argu- preters’ shared approaches to experiencing ments exist, these ideally ought to be agreed the world, for example, through language and to by all the participants in the dialogue from history. The more we practice interpretation the beginning.34 What if the resulting under- and understanding, the more we improve at standing simply reinforces a group’s biases, these processes. In everyday contexts, we of- rather than generating a new understanding ten practice hermeneutic understanding un- that is aware of them? Hermeneutics’ version awares. In reading, we slow down and are of fallibilism would suggest that the only an- implicitly asked by the subject matter and its swer in this situation is to return to the topic degree of difficulty or “strangeness” to con- again at some other time, when the effect centrate attentively. of biases may or may not be more clearly

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recognized, and so on, in a potentially lengthy tic circle back into daily life-world activity (or series of research studies. For Gadamer, the praxis), this ability is what Aristotle called outcome of an authentic dialogue can never phronesis, or practical wisdom. Practical wis- be predetermined in advance. dom enables ethical action that contributes to Interpretation becomes especially impor- the common good, by allowing us to recog- tant in orienting practice when meaning be- nize and then follow the right course of action comes elusive or difficult to grasp, or when in a specific situation. It is not a rule-based, a consensus needs to be reestablished within or rule-following, understanding of ethics that a group or team. We see in Gadamerian Aristotle is proposing. Rather, phronesis de- hermeneutics the emergence and importance notes such potentially universal, yet every- of practical wisdom (praxis), as a dimen- day behavioral qualities and attributes as pru- sion that is not simply identical with institu- dence, discernment, sensitivity, and tact, as tional norms and professional guidelines (as well as an intuitive or “natural”sense of what Kuhn and a number of sociologists of knowl- is “the good,”that is, the proper goal of action edge might seem to imply).27 Understanding to be taken for the benefit of oneself and for how wisdom is present in day-to-day tasks that of others at any given moment.36,37 can be challenging, even for the most ex- Gadamer was quite explicit regarding the perienced practitioner. Gadamer taught that significance of this dimension for his work: arriving at this understanding might involve “my whole philosophy is nothing but phrone- reentering the hermeneutic circle from a dif- sis,”he once noted in an interview.38(p54) The ferent angle, or along a different “learning work of Benner et al39 explicating the growth curve,” for example, going back and review- of novice to expert nursing practice (praxis) ing what our preunderstandings were, as we illustrates the role of judgment and phronesis discover how understanding may continue to in understanding the DIKW framework. grow and become translated into practical One of Gadamerian hermeneutics’ recur- wisdom. ring motifs is that modern scientific ratio- Interpretive approaches such as Gadame- nality and technology have systematically rian hermeneutics certainly include data and forgotten phronesis in favor of exclusive pro- information (eg, the words on the page, the motion of techne—that is, the idea of “apply- “what”of the subject matter being discussed). ing skills” as the most efficient way to solve They focus our attention on the importance problems. In the 1970s and earlier, Gadamer of context in developing knowledge or under- expressed rather prescient concern regard- standing from the ground up, for example, by ing the impact of information overload on fore-grounding the significance of life-world an “unprepared humanity,”as technology pro- experience. The references to “tacit knowl- gresses ever onward without being guided by edge”35 in many explications of the DIKW phronesis.40 framework confirm the potential significance We showed in the preceding section an and importance of the interpretive dimension example from the literature in which mea- and of its discernible ties to personal values surement of an abstract concept, spirituality, and ethics. illustrated the DIKW framework from the per- As we become more and more versed in spective of postpositivism. Christensen and the art of understanding through hermeneu- Turner41 also conducted research regarding tic praxis—whether it be through encoun- nurses’ provision of spiritual care, but from ters with patients in a clinical setting or a Gadamerian hermeneutic perspective. They taking night-school classes in how to read po- sought to understand spiritual care from the etic literature—we become experienced in perspective of registered nurses in Denmark. the ability to ask the right questions and to They used audio taped, unstructured inter- receive meaningful answers. Expressly trans- views that were then transcribed (the words lated from the experience of the hermeneu- and text are the data). Using established

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qualitative techniques, they sought to un- edge. Nursing is also a practice profession cover meaning—both from the words/text with knowledge and practice being inex- themselves and from the context surround- tricably intertwined.13,18 Knowledge or the- ing the words/text (data with meaning is in- ory supports practice by describing mean- formation). They then explicated their un- ingful relationships between information and derstanding of spiritual care as the themes concepts.43 Thus, theory is a means of repre- derived from their analysis (knowledge) and senting knowledge (defined relationships be- talked about possible interpretations and ap- tween meaningful information) and is used to plication of their findings (wisdom). describe or explain practice phenomena, to predict outcomes from decisions or action, or to prescribe a course of action. DISCUSSION The initial components of DIKW, the data, information and knowledge components can Epistemology is a way of explaining and un- be considered a direct fit with nursing prac- derstanding how we know what we know.21 tice, nursing informatics, and information sys- It influences, but is not the same as, re- tems. Wisdom, on the contrary, is more elu- search methods or selecting the type of data sive. In addition to being a knowledge and used in research. Popper remained agnos- practice profession, nursing is an ethical activ- tic as to whether quantitative or qualitative ity, requiring judgment and decisions.34 Wis- methods should be employed to test scien- dom within nursing is then a uniquely human tific hypotheses.42 Quantitative methods re- state, calling upon human attributes such as quire or presuppose a scientifically proven values, beliefs, and one’s moral and ethical (falsifiable) epistemology for the sake of reli- perspectives. ability and accuracy, for example, to preserve Given that wisdom is supported by knowl- the integrity of clinical patient data. Qualita- edge, different manifestations of wisdom may tive methods may include a hermeneutic ap- exist. Wisdom may be manifested in nursing proach, for example, to help lend a personal through “professional expertise”43 or “clinical voice to life-world experiences within an judgment.”18 It may also be manifested in car- otherwise highly technical and very special- ing and compassionate practices that support ized professional discipline. Quantitative and each patient’s particular life-world and in the qualitative research approaches have specific moral and ethical decisions nurses make ev- methods, or techniques, to answer a specific ery day.44 research question. They are not in conflict but The ANA’s addition of the concept of are ways to answer different questions.21 Al- wisdom as represented in the DIKW frame- though statistical approaches are common in work is supported by multiple philosophical postpositivist research, broad affinities exist perspectives.2 We concur that wisdom is an between the hypotheticodeductive approach important element of the DIKW framework and the hermeneutic process of question and and adds value to the roles of nursing infor- answer in dialogue. Reconciliation between maticists and nursing science. quantitative and qualitative approaches there- Some lingering philosophical questions fore no longer appears quite as unthinkable as are as follows: (1) Will computers and it once might have.42 EHR fully embody the DIKW and display The DIKW framework can be examined wisdom? and (2) Can the internal pro- from seemingly conflicting, but actually sur- cesses of nursing judgment (wisdom) be prisingly commensurable and complemen- identified and then programmed? Current tary epistemological foundations. Nurses are technology used within EHRs today neither knowledge workers—they need fundamen- computes nor displays wisdom. Computers tal knowledge to support practice and they can display data, information, and knowledge constantly generate and consume knowl- including abstract concepts. They can receive

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data and information and process it against and the ethics of our doing.15 Nurses with stored knowledge (such as rules) to produce wisdom are engaged and pay attention to the decisions or recommendations. To date, com- ethical challenges they face. They believe puters do not display tacit knowledge and the principles of morality and acceptable may never be able to fully embody wisdom. conduct are important for all people.45 However, the attainment of wisdom can be Wisdom, supported by a postpositivistic supported by computer systems. A computer perspective, often takes the form of clinical system can be programmed with information judgment, asking, “Is this body of scientific and knowledge to promote human learning, knowledge applicable for patient X at the cur- understanding, and personal growth, which, rent time?” From the Gadamerian hermeneu- in turn, support the development of human- tic perspective, wisdom takes the form of centered wisdom.7 praxis—the day-to-day decisions made by Wisdom is an attribute of human beings. nurses with experience levels ranging from Thus, even though computers do not them- novice to expert.18 selves possess wisdom, nurses who use com- Nursing is a holistic practice, expanding be- puters can exhibit wisdom in their practices yond the physical dimension to include so- and can develop wisdom through the use of cial, interpersonal, spiritual, and other dimen- computer systems. Nursing informatics spe- sions. Like other professions, it is both an cialists support developing wisdom through art and a science. The caring practices and sound management and communication of discernment implicit in “nursing judgment” data, information, and knowledge. The appro- are often called the art of nursing. Many of priate and ethical application of knowledge the judgments nurses make can be identi- and theory is understood as wisdom.2 fied and programmed into an EHR, but heal- The DIKW framework can support the ing relationships cannot be reduced to objec- translation between research and practice. tive data, nor can they always be predicted— Understanding how the concepts of the nevertheless, we know they exist and recog- DIKW framework overlap and interact will as- nize them when we experience them.16 sist clinical nurses in the critical evaluation and implementation of research.17 The DIKW framework facilitates the CONCLUSION nurse’s ability to represent ethical practices. As knowledge workers, nurses collect data Data, information, knowledge, and wis- and information and make decisions that af- dom are foundational concepts for nursing fect individuals, families, and communities.2 and nursing informatics. We conclude that Wisdom is intertwined with the principles the DIKW framework provides a founda- of doing things right. Wisdom and ethics are tion for linking theory and practice. We pre- attributes of each other. In addition, wisdom sented 2 epistemological perspectives, post- and ethics share the characteristics of judg- positivism and Gadamerian hermeneutics that ment, caring, and responsibility. “Clinical contribute foundational elements to nursing judgment requires moral agency, insight, informatics and the DIKW framework. We dis- skilled know-how, and narrative reasoning cussed how both approaches conceptualize about patient transitions.”18(p103) Proficient and clarify the aims of informatics, and de- nurses show clinical wisdom with ethical scribed ways to study phenomena from both discernment by demonstrating the ability perspectives using the DIKW framework. The to think critically and to act and practice combination of postpositivism and Gadame- responsibility, by applying abstract thinking rian hermeneutics provides an appropriate and knowing to implement specific acts of epistemological basis for understanding the care within specific situations. Wisdom is DIKW framework. Awareness of the assump- about comprehensibility, understandability, tions about knowledge in both approaches

Philosophical Approaches to Nursing Informatics 17

will allow nurse informaticists, nurse schol- mation, knowledge, and wisdom in a mean- ars, and nurse researchers to link data, infor- ingful way.

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