Data, Information, Knowledge
In order for us to move forward as a scientific discipline we must generate data about patient encounters and the different systems of health care delivery. These data can then be organized in ways that yield information, and the information in turn can be organized, explored, and tested to confirm what we know or to reveal new knowledge. The links between practice, research, and theory are data links, and our science is only as good as our data and what we do with it. This section deals with some of the new advances in this area of information management.
The first chapter in this section is a well-reasoned and thought-provoking debate about the relationships among nursing theory, nursing research, and nursing practice. After defining the terms, Blegen and Tripp-Reimer discuss the advantages and disadvantages of three positions. First, nursing theory, research, and practice should be kept as separate categories; second, the three categories should be closely connected; and third, the categories should be separate with bridges between them. They indicate their choice of the third position with middle range theory providing the connecting bridges. This position is now a real possibility because of the development of taxonomies of diagnoses, interventions, and outcomes that provide the "skeletal framework for nursing knowledge." This clear overview of the relationships among theory, research, and practice should provide good debate and discussion among all those interested in knowledge generation and use.
The link between knowledge development and the computer is explored in the next chapter. Bakken and Costantino provide a thorough overview of the challenges related to transforming nursing data into knowledge. The authors begin by addressing the question of why traditional automated nursing systems have not fostered the development of nursing knowledge. They review the development of standardized nursing terminologies and the evolution of standards for data exchange in information systems. The role of informatics in fostering knowledge development in nursing is reviewed through the system design framework of the National Commission on Nursing Implementation Project. The framework's four types of information system processes (data acquisition, storage, transformation, and presentation) are reviewed. Several examples are given that illustrate the interaction among information and information processes. These include data mining and knowledge discovery techniques for analysis of data repositories. The authors conclude that technological building blocks such as standardized terminologies and integrated systems are necessary but not sufficient for the development of nursing knowledge. Computer competencies related to the acquisition, organization, and analysis of large repositories of clinical data are required. The chapter ends with the formulation of three questions that demonstrate the evolution of nursing knowledge through the documentation of nursing care. Overall, the chapter illustrates the central role of the computer in building nursing science.
Using data, rather than tradition, to guide practice is referred to as evidence-based practice, the subject of the next chapter by Goode and Krugman. The authors begin their chapter by reviewing the history of the movement. In nursing this began as research utilization in the 1970s but the term was not understood by other disciplines and it did not address patient preferences. The evidence based practice movement was begun in England in the early 1990s and has been dominated by medicine. Evidence- based practice in nursing is more recent. The authors present a multidisciplinary model they and their colleagues have developed. The main source of evidence constitutes a research core, but nine other sources of nonresearch evidence supplement the research core: patient record review, quality improvement and risk data, standards, infection control, patient preferences, clinical expertise, benchmarking data, cost-effective analysis, and patient's pathophysiology. Patient preferences can override all other sources. The authors review each type of evidence and include numerous web addresses to help locate evidence. They conclude that it is still unclear what best evidence is. This is a helpful chapter that will clarify a recent and growing movement in health care: using the best evidence to improve care practices.
One type of evidence is benchmarking, which is defined by Lin, Truong, Smeltzer, and Williams-Brinkley in the next chapter as the continuous process of comparing measures of services and practices against those of excellent competitors in order to improve practice in an organization. In this era of the Internet and rapid access to information, the consumer is empowered and desires comparison information on quality. According to the authors, successful health care organizations increasingly rely on benchmarking to improve quality and maintain a competitive advantage. The authors discuss three types of benchmarking: internal, competitive, and functional. They also overview the four phases of the benchmarking process: planning, analysis, integration, and action. It is most typical to benchmark performance measures (e.g., length of stay, total expense, number of patient days), but these measures do not indicate how one organization achieved better results. Thus benchmarking on, for example, treatments and medications administered, surgeries performed, and room maintenance services is also recommended. The authors say that benchmarking provides guidance and direction for change to improve practice, but users need to define measures carefully to be consistent with their objectives and needs. A list of reminders for the successful use of benchmarking is included. The chapter is a good overview of one popular data management tool that health care organizations are using to improve services.
The next chapter by Predko addresses the important topic of distance technology. Offering health care via distance technology (telehealth) can facilitate consumer access and convenience. Predko says that the challenge in telehealth is maintaining and improving quality while keeping costs reasonable and improving access. In her chapter she addresses the use of distance technology in education, practice, and research. Throughout the chapter she poses numerous challenging questions, for example: Should future growth at universities be in traditional classes or in telecommunication? How are the roles of teachers and students changed by distance education? What types of data are important to support clinical decision making and are worth monitoring? How can we assure equitable distribution of home care technology? Predko reviews the progress made by nursing as demonstrated in the various position statements on distance education issued by nursing's professional organizations. She overviews the benefits, disadvantages, and barriers to the use of distance technology in education, practice, and research and makes recommendations for teaching distance education courses based on her personal experience. While the health care industry lags behind other industries in the use of information systems, nursing has emerged as a leader in the use of distance technology. Predko urges nurses everywhere to continue to increase their knowledge and skill in distance technologies. Her chapter is a great overview of the state of the art in this area.
The final chapter in the section, by Eland, presents a vision of information exchange in a future that is not so distant. This chapter is a good companion to the previous one. Eland logs us on to a computer using a retinal eye identification security system. Courses are available via the Internet, and most students are enrolled as distance learners. They can select courses from any university in the world. Libraries are electronic, and office hours are conducted via a Web camera. On-line texts are complete with moving video clips of actual clinical situations hyperlinked to related topics. The video clips are also used by family members who need to learn complicated procedures. Providers communicate with distant colleagues and provide consultation over the Internet. Research is conducted over the Internet, with immediate access to the data for analysis. As you read Eland's vision, ask yourself what has to happen to make the vision a reality. Do you like all of her vision? What part would you change? How does the vision change the nature of the university? How does it change the role of the nurse?
While nursing has made tremendous progress in the area of the use of distance technology and information management, we still have work to do to create a preferred future. Some of the challenges include better preparation of nurses with computer skills, the need to teach clinical decision-making skills in a more systematic way, continued integration of distance technology, the need for widespread use of standardized languages for documentation of care, and integration of nursing data in state and national databases. Although we will continue to conduct and value single research studies that collect small samples of data, we must also begin to collect data in standardized forms on the computer for each patient encounter. These data can be aggregated across units and facilities and connected with other data to build large sample sizes that can be used for sophisticated data analysis. Practitioners and researchers must work together to generate and analyze the data and then to improve practice based on what we learn. This is the computer age. We have made progress but still have much to do.
Nursing Theory, Nursing Research, and Nursing Practice
Connected or Separate?
In the last century, nursing progressed from a largely "on-the-job training," temporary occupation for unmarried women to one in which its members were fully educated and licensed, highly respected, and integral to the conduct of the health care professions. In the last half of the 1900s, nursing science developed rapidly and the knowledge that underpins the nursing profession grew at an amazing speed. In this new millennium, we must keep the momentum going and continue building this knowledge through all available avenues.
As nurse leaders examined the developing knowledge, they expressed concern about the divergent patterns that nursing knowledge development were forming. Knowledge was developing separately in three areas: practice knowledge, knowledge based in research or science, and theoretical knowledge. While most nurse scholars called for integrated knowledge, the development processes continued separately (Conant, 1967; Fawcett, 1978a; Fawcett & Downs, 1992; Jacobs & Huether, 1978). The concern about the lack of knowledge integration leads to the proposition addressed in this chapter: Should nursing knowledge be developed in three separate areas or as one seamless whole?
Nursing practice is the "performance of services for compensation in the provision of diagnosis and treatment of human responses to health or illness" (ANA, 1990). The knowledge that nurses use while engaging in practice comes from many sources and is learned initially in the courses taken during undergraduate education. These courses are carefully selected from all disciplines: biophysical sciences, social sciences, humanities, and finally nursing science. The courses in nursing science present knowledge based in other disciplines and knowledge generated by nurses. This nursing knowledge tends to be practical and is applied as soon as possible in a clinical setting. Nurse educators work diligently to present knowledge based in research and organized around a conceptual framework or nursing theory. Articles in nursing education encourage faculty to include nursing research and to use nursing theories. These exhortations emphasize the existing separateness of practice, research, and theory.
Nursing research is the conduct of systematic studies to generate new knowledge or confirm existing knowledge. The fact that nursing research is not often informed by theory and is seldom applied in nursing practice has been lamented for some time. While optimistic about the increase in application of research findings, most authors point to significant barriers to research utilization (Baessler et al., 1994; Carroll et al., 1997; Coyle & Sokop, 1990; Pettengill, Gillies, & Clark, 1994; Titler, 1997). The idea of applying knowledge from research in practice implies the crossing of a boundary. This boundary is composed in part of difficulties finding, reading, understanding, and preparing the research for application. Another part of the boundary between research and practice is the different orientations of nurses who conduct research and those who care for patients directly. The orientation of nurse researchers leads them to increase the validity of the general knowledge produced by their studies by removing or controlling the influence of unique individual characteristics of each patient or subject and the setting. Nurses oriented to practice must focus on those individual characteristics to provide care that truly meets each patient's needs. These different perspectives and tools continue to keep knowledge from research separate from knowledge used in practice until a nurse takes pieces of the knowledge from one arena and uses it in the other.
Nursing theory, on the other hand, is also portrayed as connected to
neither practice nor research. Three reviews of research articles conducted to
identify the nursing theory underpinning the research found that few of the
studies were related to nursing theory. Silva (1986) found that 53 of the 62
research articles she reviewed were not tied to nursing theory. Moody et al.
(1988) found that only 3% of clinical research articles actually tested nursing
theory. More recently, Fawcett (1999) reviewed all articles published in
Many conceptual models emerged in the late 1960s to early 1980s as efforts to define the discipline and foster curricular reform. Although these models were historically essential in nursing's articulation of its identity, they evolved parallel to, rather than interwoven with, research (Blegen & Tripp-Reimer, 1994). These models were statements of nursing philosophy and ideology but did not present knowledge that could be applied directly in practice. They were separate from the world of nursing practice and were neither developed from research nor tested through research. Nursing theory as a type of knowledge in that era was often considered by both practitioners and researchers to be too abstract to be useful. As others have noted, nurses seemed to believe that, in order to be theory, the knowledge needed to be obscure and lack immediate use and meaning (Levine, 1995). Therefore, theory was relegated to a place separate from other types of nursing knowledge. When the grand theories of this era were used, they were most often superimposed on educational, clinical and research environments with little regard to the fit. While the models are still selected by schools and hospitals as organizing frameworks, they do not drive practice, nor do they serve as frameworks for significant research programs.
In the 1980s, following Yura and Torres' (1975)
National League for Nursing survey of curricular commonalities in baccalaureate
schools of nursing, nursing scholars identified four common constructs
(man-human, health, society-environment, and nursing) and declared that the
metaparadigm of nursing had been established (Fawcett, 1978b; Flaskerud &
Halloran, 1980; Newman, 1984). Scholars gratefully accepted this paradigm for
nursing, in large part because perspectives in the philosophy of science had
made achievement of disciplinary status contingent on having a paradigm. However, as
This chapter addresses several questions regarding the categories of nursing knowledge. Are the three categories still separate, and if so, is that situation inevitable? What are the advantages of keeping these categories separate? What are the advantages of connecting them? Can the three categories be separate and still useful? To stimulate debate, we present three positions: (1) keep the categories separate, (2) closely connect them, and (3) keep them separate but structure the knowledge with built-in bridges.
KEEP THE THREE CATEGORIES SEPARATE
Each category of nursing knowledge will develop most fruitfully when tended carefully with full focus on one primary category. Nurses with interest and skills in each of the three areas have different perspectives. Nursing practice focuses on specific unique patients with immediate needs in concrete situations. Researchers, however, must carefully control the unique features to produce findings that can be applied across settings to many patients. Theorists focus on general abstract knowledge that may or may not be directly applicable in practice or tested in research at any given time. Their job is to develop the metanarrative of nursing; to articulate the patterns of knowledge, naming, defining, and relating concepts and patterns; to sketch boldly the phenomena of nursing and nursing care; and to clarify how nursing is a unique discipline (Reed, 1995).
Most nurse theorists, researchers, and practitioners currently have highly developed skills in only one of these areas, and knowledge in each category is developing well. Continuing in this manner will produce the knowledge needed and will use the currently developed skills and abilities efficiently. Therefore, the first position is to continue doing what has been successful for the past 30 years.
If the categories of knowledge are kept separate, we must continue to develop the mechanisms to carry nursing theory both to practitioners to inform their practice and to researchers to guide their work. That is, a boundary- spanning role must be developed for persons who move and translate knowledge from each category to nurses working in the other categories. Initially, nurse educators would fill this boundary-spanning role by organizing the knowledge learned by beginning students around nursing theories and capturing the knowledge available from existing research and using it to support nursing practice knowledge. New curricular developments attempt to do just that (Walker & Redman, 1999).
After nurses complete their basic education, they must then rely on boundary-spanning activities in the form of continuing education, workplace facilitators, and publications for practicing nurses. Doctorally prepared clinical nurse researchers often facilitate the application process in practice arenas (Titler, 1997). Publications providing practitioners with nursing theory and current research findings would also assist in these efforts. Several publications have recently made valuable contributions in this area, e.g., Applied Nursing Research, Clinical Nursing Research, Nursing Scan in Administration, American Journal of Nursing, MedSurg Nursing, Dimensions of Critical Care Nursing, and the Online Journal of Knowledge Synthesis for Nursing.
Research utilization methods have been developed by nurses over the last two decades to provide this boundary- spanning role (Burns & Grove, 1997). While this type of activity is greatly needed by many applied professions, nurses are unique in constructing these methods in great detail. The profession has responded eagerly to this approach. Research utilization projects, often conducted by groups of staff nurses with advice and consultation from nurse research experts, have developed intervention protocols successfully for use in practice (Titler et al., 1994). The research utilization process is an example of successful boundary spanning across the knowledge categories of research and practice. More recently, evidence-based practice efforts have drawn knowledge from theory and practice traditions as well as empirical research to build guidelines and protocols for practice (Goode & Piedalue, 1999).
To reach across the categories of theory and research, boundary-spanning persons will need to identify theoretical developments that need testing and form research questions that need study. Research findings that inform theory development must be communicated back to the theoreticians. Practice problems without current solutions, or with questionable current solutions, must be identified and delivered to researchers for study. Researchers generally take on the role of boundary spanners themselves. That is, they have attempted to frame their research with theory and to derive research questions from practice. As previously noted, however, this has not been totally successful.
Keeping the categories of knowledge separate would allow the continuation of the present pattern of development, with which nursing has made great strides. Practitioners use practice knowledge as they provide care. Theoreticians focus on development of broad abstract statements of what nursing is and does, while researchers discover and develop knowledge from nursing's specific perspective. To facilitate fruition of each category separately and to use this knowledge in practice, boundary spanning persons are needed to package and deliver knowledge from nurse theorists to researchers and practitioners and back. Basic and continuing nursing education, research utilization, evidence-based practice, and specialized publications have all functioned to span the boundary between research and practice. To facilitate continued progress in this mode, we must find efficient ways to span the boundaries between theory and practice and between theory and research.
CATEGORIES MUST BE CLOSELY CONNECTED
The professional discipline of nursing must have a body of knowledge that is unique, coherent, and as seamless as possible. There must be one unified body of knowledge that belongs to nursing. This knowledge must be organized by theoretically identified concepts, patterns, and relationships; the statements of this knowledge must be generated from and tested by systematic research; and knowledge needs must be identified in practice and generated knowledge applied immediately to practice. Anything less than full connectedness will continue the current pattern of separateness and the ongoing necessity for the special roles of boundary spanners.
Models for accomplishing this connectedness have been described. The ideal model brings together academic researchers, nurse theorists, and practicing nurses to identify knowledge needs, to carry out research projects, to create and refine theory, and to bring research findings systematically into nursing practice. Three subtypes can be identified. The first is the researcher-practitioner collaboration. Two examples of this model come from northern California and involve collaboration among several health care agencies and nurse research experts (Chenitz, Sater, Davies, & Friesen, 1990; Rizzuto & Mitchell, 1988). Another example comes from the Midwest and describes a collaborative research project that began as a utilization project, became a research conduction project due to the lack of adequate base for interventions, and concluded as the results of the research were used and evaluated in practice (Blegen & Goode, 1994).
The second type of collaboration is the theorist-practitioner model. Examples of this kind of collaboration are found in discussions of implementation of the conceptual models. The language and focus of a conceptual model are implemented through the nursing documentation and organization of a hospital or other patient care facility. Unfortunately, it is difficult to analyze the success of these efforts. How can we determine whether implementing model A or model B in a hospital leads to better outcomes? Real world problems are too complex to conclude unequivocally that the model implemented resulted in the changes specified and that the changes enhanced patient outcomes. Fawcett (1999) suggested that nursing needs two dominant provider types, which she labels nurse scholars. The first type, prepared in nursing doctoral (ND) programs, would integrate research and practice in caring for individual clients. The second type, prepared in doctorate of philosophy programs (PhD), would integrate nursing theory and practice with groups of patients.
The third type of collaboration is the researcher-theorist group, which most often evolves from an exploratory qualitative approach to research: the grounded theory approach. Yet another suggestion for increasing the connectedness of the production and use of knowledge is offered by Boyd (1993). The nursing practice research method features the relationship between the nurse researcher- as-clinician and the patient. The research process is collaboration between nurse and patient; it is therapeutic to the patient and leads to development of the nurse. It can be questioned whether the knowledge produced by these efforts is generalizable beyond the setting and patients involved in the project. Even researchers from the "perceived" view call for the creation of knowledge that can be used by all nurses, i.e., knowledge that is generalizable (Schumacher & Gortner, 1992). The greater the need for knowledge that is generally useful by all nurses, the less this approach will be satisfactory.
There are no examples of models combining all three knowledge areas. While needed—and this need is often discussed in published literature—no working models have been described. One recently suggested approach may be able to facilitate this. Theories can be "tested" using means other than traditional empirical research methods. Silva and Sorrell (1992) suggested that there are four approaches to testing theory: verification through correspondence with empirical research, testing to verify through critical reasoning, testing through verification of personal experiences, and verification through assessment of problem-solving effectiveness. If a theory were tested with all these approaches, it would clearly increase the connectedness between practice, theory, and research. However, theory testing using any one of these four methods also involves advanced skills that many practicing nurses either do not have or have little time to use. If the theories being tested with personal experience or problem-solving effectiveness were closer to practice and more narrow in scope than the grand theories, the possibility of practicing nurses carrying out these tests is more likely than if the theories were conceptual models or grand theories.
While collaboration is generally to be recommended and is essential if we set out to develop one coherent, seamless body of knowledge, there are limitations to the extent of collaboration that can actually take place. It is difficult to cross the differing perspectives of the persons involved. Practitioners focus on individual and unique patients; researchers focus on systematically collecting knowledge that transcends the individual subjects from whom they collect data; and theorists focus on general and abstract concepts and relationships among them. A great deal of time and effort must be expended to enhance communication among collaborators.
This highly connected approach to nursing knowledge would put to rest the problem of separated areas of knowledge; however, working in teams that draw persons from multiple settings consumes a great deal of time and other resources. With a highly connected approach to nursing knowledge creation and use, the boundary-spanning activities encompassed by research utilization would no longer be needed. This would release some resources for use in the collaboration needed for the success of the connected approach. At this point in time, the actual success of this model is questionable.
ESTABLISH STRONG CONNECTIONS BETWEEN SEPARATE CATEGORIES
Nursing knowledge must be separated by type of knowledge (action-oriented specific practice applications, controlled systematic and narrow research findings, and abstract and general theory) and by the perspectives of the nurses associated with each category. The development and the use of nursing knowledge are facilitated by keeping these separate and allowing clear and concentrated application of the different approaches used for each type. However, we need stronger connections than are presently provided by the boundary-spanning activities discussed in position one. These connections should be structural and intrinsic to the knowledge itself rather than dependent on boundary spanners. If the knowledge developed was closer to practice, amenable to research testing, and built around structures intrinsic to the discipline of nursing, we would then have the best of all worlds: separateness for development and connectedness for application.
The best solution for keeping the three separate categories more closely connected is to use middle-range theory as the connecting point. Middle-range theory, when developed from research and thoughtful consideration of practice and tested by other research projects, does represent the most valid and useful type of knowledge available in nursing and other disciplines (Lenz, Suppe, Gift, Pugh, & Milligan, 1995).
Middle-range theory provides the means of articulating general knowledge, confirmed by the specific results of research projects, to nurses in clinical practice. When middle-range theory is used to guide research and knowledge development, the theorist and researcher are either the same person or two persons focusing on the same carefully delineated topic. The scope of knowledge within the topic area is narrower than the grand theories and the metaparadigm concepts. The restriction of scope allows for far more precision and depth than the grand theories and conceptual models have allowed. This precise, in depth and focused knowledge can then be used to inform and guide practice in specific and useful ways. Each middle range theory is more narrow and precise, and yet, as midrange theories develop, they will eventually produce a body of knowledge that covers a broad range of nursing activities.
Theories of the middle range were first suggested by the sociologist Robert K. Merton. The discipline of sociology also initially developed large theories attempting to differentiate sociology from other disciplines and to explain all of social phenomena with one effort. Merton (1967) responded by suggesting middle-range theories and differentiating them from the grand theories. Middle- range theory can be used to guide empirical inquiry because it lies between the minor working hypotheses that evolve in abundance during day-to-day practice and the all-inclusive systematic efforts to develop one unified theory that would explain all behavior. It is intermediate to the general theories, which are too remote from specific classes of behavior to account for what is observed, and to those detailed orderly descriptions of particulars that are not generalized at all. Middle-range theory, according to Merton, involves abstractions, but they are close enough to observed data to be expressed in propositions that permit testing with systematic research.
Merton suggested that the search for the perfect grand theory led to a multiplicity of philosophical systems in sociology and, further, to the formation of schools, each with its own cluster of masters and disciples. Nursing perhaps has fallen to a similar fate. That is, we became differentiated from other disciplines but also became internally differentiated not in terms of specialization, as in other sciences, but in terms of schools of philosophy, held to be mutually exclusive and largely at odds. It is time to refocus from discussing these larger philosophical systems to producing knowledge that explains patient-related phenomena and helps in the choice and evaluation of interventions.
Merton further described the middle-range orientation as one that involves the specification of ignorance. Rather than pretend to have knowledge when it is, in fact, absent, the work on middle-range theories expressly recognizes what must yet be learned in order to lay the foundation for more knowledge. It does not begin with the task of providing theoretical solutions to all the urgent practical problems of the day, but addresses itself to those problems that might now be clarified in the light of available knowledge and to the identification of problems about which we know very little.
To make use of the knowledge provided by middle range theories, practicing nurses would need some grasp of research methods but they would not have to read and critique directly the often complex reports of research methods and findings. In addition, practicing nurses would not have to attempt to apply the global, highly abstract grand theories to everyday practice. Middle-range theories, developed and tested by research, would contain much more specific descriptions of human responses to health and illness and the nursing interventions applicable to these responses. Although understanding the theory and deriving specific nursing actions would be necessary, these activities would not be as daunting with theory developed in the middle range as they are with the grand theories.
Some boundary-spanning activities would still be needed. While the knowledge articulated with middle range theories is much closer to practice, it still must be located and critiqued. Nurse educators and group leaders for evidence-based practice projects could provide this necessary assistance. Their job would be much easier with theory in the middle range that had been tested systematically by researchers. Knowledge built in this way is more easily synthesized: the cumulation of knowledge across individual studies occurs as part of the process of conducting research and testing a theory. Persons actively engaged in evidence-based practice could provide an additional service by formally feeding back to the researchers the evaluation of practice guidelines and protocols. This would provide a test of pragmatic usefulness for the knowledge.
Recent developments in nursing knowledge could provide other strong bridges connecting the three categories of nursing knowledge. In the last decade of the 20th century, more of the theoretical work has been in the middle range. Some of these middle-range theories, however, were drawn from other disciplines and did not cohere naturally within the practice discipline of nursing. While these theories were used to support nursing research, they did not fit as well within the practice arena. Liehr and Smith (1999) list five approaches to developing middle range theory. We suggest that recent developments in nursing knowledge structures provide another way to ground these theories within the discipline.