i Nurse-led ontology construction: A design science approach. Philip John Shields RN BA Nursing (Hons) College of Health and Biomedicine, School of Nursing and Midwifery Victoria University, Melbourne Submitted in fulfilment of the requirements of the degree of PhD (April, 2016) ii Abstract Purpose: Most nursing quality studies based on the structure-process-outcome paradigm have concentrated on structure-outcome associations and have not explained the nursing process domain. This thesis turns the spotlight on the process domain and visualises nursing processes or ‘what nurses do’ by using ‘semantics’ which underpin Linking Of Data (LOD) technologies such as ontologies. Ontology construction has considerable limitations that make direct input of nursing process semantics difficult. Consequently, nursing ontologies being constructed to date use nursing process semantics collected by non-clinicians. These ontologies may have undesirable clinical implications when they are used to map nurse processes to patient outcomes. To address this issue, this thesis places nurses at the centre of semantic collection and ontology construction. Method: Design science methodology enables nurses to contribute their process domain semantics ‘first hand’. A sample of nurses working in various specialities was recruited to draw their process domain using node-arc-node ‘graphs’. Graphs are a visual representation of the language used to construct ontologies. Graphs contain semantics supplied by nurses; graphs are used to construct OWL-DL ontologies. OWL-DL ontologies are used because they are web-based and have a logic-and-rule construction. The ontologies were analysed by robots to evaluate their term ‘closeness’ and logic consistency. Results: Graphs depicting four different process domains were produced and used to construct OWL-DL ontologies. Graphs revealed differences from one process domain to another; clusters of ‘responsibility’ varied between graphs and the focus on nursing roles varied from graph to graph. Graphs also revealed ‘hidden’ processes. The software robots graded the ‘closeness’ of terms between ontologies and found all of the ontologies had exclusive terminology. Three of the four ontologies were logically consistent. Conclusion: Semantic technologies have proven to be a valuable analytical tool to describe the nursing process domain. Graphs allow nurses to input process semantics directly into ontology construction. Robots can evaluate ontologies constructed from nursing graphs. iii Student Declaration Doctor of Philosophy Declaration “I, Philip John Shields, declare that the PhD thesis entitled ‘Nurse-led ontology construction: A design science approach’ is no more than 100,000 words in length including quotes and exclusive of tables, figures, appendices, bibliography, references and footnotes. This thesis contains no material that has been submitted previously, in whole or in part, for the award of any other academic degree or diploma. Except where otherwise indicated, this thesis is my own work”. Signature: Date: April, 2016 iv Acknowledgements This research was supported by Victoria University, College of health and biomedicine, nursing & midwifery. I gratefully acknowledge my full-time scholarship and various grants. I wish to express my thanks to: My supervisors Associate Professor Liza Heslop for her guidance and encouragement throughout the course of the PhD and Dr Sai Lu for her assistance relating to the development of the thesis and guidance with submissions to various conventions. My wife Jenny for her patience, support and encouragement during the course of my many studies. The many nurses who provided valuable feedback for my presentations. v Table of Contents ABSTRACT .................................................................................................................................. II STUDENT DECLARATION .................................................................................................... III ACKNOWLEDGEMENTS ....................................................................................................... IV TABLE OF CONTENTS ............................................................................................................. V LIST OF FIGURES ..................................................................................................................... X LIST OF TABLES ..................................................................................................................... XI CHAPTER ONE: INTRODUCTION TO THE THESIS ....................................................... 12 1.0 Introduction to the chapter ..................................................................................................................... 12 1.1 Background to the thesis ......................................................................................................................... 13 1.1.1 The lack of nursing process semantics .............................................................................................. 13 1.1.2 The lack of studies which include Donabedian’s process domain .................................................... 14 1.2 The problem this thesis addresses .......................................................................................................... 15 1.2.1 Acquiring semantics from front-line nurses ...................................................................................... 15 1.3 Research question .................................................................................................................................... 15 1.4 Research aims .......................................................................................................................................... 15 1.5 Significance .............................................................................................................................................. 16 1.6 Methodology ............................................................................................................................................. 17 1.6.1 The study framework ........................................................................................................................ 17 1.6.2 The study population ........................................................................................................................ 17 1.6.3 Semantics collection methods ........................................................................................................... 17 1.6.4 Semantics analysis ............................................................................................................................ 17 1.7 The thesis’ outputs ................................................................................................................................... 18 1.8 Overview of the thesis ............................................................................................................................. 18 1.9 Glossary .................................................................................................................................................... 19 vi CHAPTER TWO: EVIDENCE OF NURSES USING PROCESS SEMANTICS TO CONSTRUCT ONTOLOGIES .................................................................................................. 28 2.0 Introduction to the chapter ..................................................................................................................... 28 2.1 Evidence of nurse process semantics to construct ontologies .............................................................. 28 2.2 Linking Nurse Sensitive Indicators (NSIs) with relationships across a framework .......................... 31 2.2.1 Donabedian’s conceptual framework................................................................................................ 31 2.2.2 Definition of NSIs ............................................................................................................................. 32 2.2.3 NSIs in the structural domain ........................................................................................................... 32 2.2.4 NSIs in the process domain............................................................................................................... 32 2.2.5 NSIs in the outcome domain ............................................................................................................. 33 2.3 Nursing structure to outcome studies .................................................................................................... 34 2.3.1 The Aiken study ................................................................................................................................ 34 2.3.2 The Duffield study ............................................................................................................................ 35 2.3.3 Irvine (Doran)’s Nursing Role Effectiveness Model ........................................................................ 36 2.3.4 The NREM in a ‘real’ nursing process domain ................................................................................ 37 2.4 Manual and automated extraction of terms by comparing their ‘closeness’ ...................................... 38 2.4.1 Fully automated ‘rule sets’ to compare semantics ............................................................................ 39 2.4.2 Semi-automated NSI acquisition studies .........................................................................................