Book review: "Nursing Informatics and the Foundation of Knowledge" (long book - long review) - The Koch Family
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Book review: "Nursing Informatics and the Foundation of Knowledge" (long book - long review)

Happy New Year to everyone!

Last spring I requested a book for review and received three c/o and with thanks to Jones & Bartlett Learning Nursing. Finally, I've picked up the second - and about time it seems - as on this first day of 2014 the publishers are planning the 3rd edition. This book provided a break from virtual matters being a door-stop of a book; 538 pages, excluding abbreviations, glossary and index. In addition to this physical rendering the publishers emphasize an online presence for this and other books. Inside the cover there is a card with an access code to unlock the companion website for online resources for readers, students and lecturers. The account setup is straightforward and there are additional student exercises beyond those in the book.

Informatics is by definition a challenge for authors and publishers. Even though published in 2011 - 2012 time is at work. From the outset then the team involved in this text are to be congratulated on what is a monumental task in scale and time.

The foundation of knowledge in the title refers to the adopted conceptual framework - the foundation of knowledge model, which is illustrated at the start of the book's sections and especially section I on the building blocks of nursing informatics.

The foundation of knowledge model was itself quite a hook for me.
The model includes bits, bytes, data and information and from this arise:
  • knowledge acquisition
  • knowledge processing
  • knowledge generation
  • and knowledge dissemination
- with all of these influenced by and influencing feedback (there is an illustration in the sample chapter). The model describes people as information systems. Although the diagram presents a structure for the model, and it fits this informatics context very well and provides a link throughout the book it is not convincing in terms of subjects, agents, and knowledge disciplines. Admittedly the foundation of knowledge model is high level like Hodges’ model. Similarly, it is not prescriptive in terms of how events, phenomena are characterised. Data, information, knowledge and wisdom are however, the most fuzzy of concepts and subject to ongoing philosophical debate. I'll reflect a little more on this later. As already noted the model works here and I see online that a couple of students (and no doubt a great many more) have utilised the model in e-portfolios.

Each chapter has a listing of key terms, which are highlighted in the text. There are reflective questions at the end of each chapters. Chapters are concise, well referenced across various media and are all accessible and evident of a great editorship. There are a couple of longer treatments of certain and well chosen topics. Within chapters there are brief diversions in boxes on a related theme, for example in chapter 3, box 3.2 on ‘storage capacities’. I’d almost forgotten about EPROM and RAM, even though I used to purchase computer programs on EPROMS and ROMS in the 90s. Although abbreviations still abound, these abbreviations have become rather transparent now - and may say more about the generational scope of the authors - including this one? If these are going to be included then where is ‘GPU’, ‘SSD’ …? This is a difficult balance to strike, but mention of these struck me as antiquated and date the text. ('GPU' is hardly new - 1998 c/o Nvidia)

With two major companies referred to early on, open source is explained on page 43 and in the examples of software programs that are listed. The book is courageous in several respects introducing the model, listing software and specific technology examples, some of which can be brief in terms of market longevity. The emergence of the cloud is discussed and provides a current flavour, as with usability (‘UX’). Although the authors are clearly leaders and advocates for nursing informatics and the technologic, the enthusiasm is tempered.

The limits and complexity of AI artificial intelligence are raised in addition to the revolutionary progress. Chapter 4 on cognitive informatics I found personally fascinating, as it reassures me about my interest in the potential of combining conceptual spaces, threshold concepts with Hodges’ model. As a result I previously posted items from the book about cognitive informatics and another relating Beauchamp and Childress’s four principles of health care ethics to Hodges’ model.

Chapter 5 continues the consideration of the limits and challenges posed by technology in exploring the theoretical approaches to health care ethics. The standards for e-health ethics will now be tested with the fate of the .health domain (deliberated online at HIFA2015 to follow...). I wonder if this debate will figure in the 3rd edition? Clearly there are implications for the governance of such a domain. As the chapter points out many ethical e-health standards are voluntary.

As an individual and a reviewer of book with international scope and a discipline with international global aspirations you are acutely aware of your parochial situation. When I look at the UK (Northwest England!) and nursing informatics it seems, with some exceptions to have failed to make a mark in nursing. Yes, colleagues and I use an electronic health record, but there is so much more that could be provided in terms of purposes, functionality and reports. The majority of student nurses I speak to do not seem to be primed let alone tutored for the wider informatics world they will enter as practitioners. So much more that could be done with mobile technology, caseload management tools, research tools. Perhaps this is why as I read of - the use of decision support systems and expert systems (p.77) – I thought “Get real!”. How accessible are such tools to the majority of nurses? Speaking from Wigan Pier at least, if it is 'nursing informatics' you seek then you must be westward bound. It appears there is quite a difference in the esteem of nursing informatics in the USA and UK? - and my review reflects this. Jocularity aside there are two serious points here.

1. The book is clearly USA centric, but it really is relevant to readers elsewhere (I thought there might be a problem registering on the website, but there was no .
2. The other point concerns activism.

When there is an opportunity should we advocate for nursing? Is there scope for this within a nursing informatics text? Even in ‘developed’ nations we should take nothing for granted be that the UK - rickets, TB, sexually transmitted diseases in older adults, obesity; or the United States with the potential impact of climate change and health inequality (MacKenzie, 2013, America's hidden epidemic of tropical diseases). The complexity of nursing and health is also apparent while reading that informatics can serve to check compliance with antibiotic regimes, you simultaneously reflect on the need to reduce the general prescribing of antibiotics and the correct administration and management when they are utilized.

My interest in and exposure to informatics and the humanistic-mechanistic axis within Hodges’ model brought me to the socio-technical literature. Even though socio-technical aspects of nursing and nursing informatics abound implicitly in the book (chapter 6, page 100 and elsewhere – chapter 16) ‘sociotechnical’ or ‘socio-technical’ does not have a place in the index. Although they rarely come across it – hence my thoughts above – I explain something of classification and coding to the student nurses who visit our team. Chapter 7 is a very informative contribution on this subject by one of several international contributors (all listed at the book’s start). How can nursing informatics make an impact if nursing students are not aware of the existence of nursing terminologies and approaches – enumerative and ontological - to the same? Nurses should be aware of the international standards associated with their profession - nursing terminologies included. Chapter 8 on nursing roles, competencies and skills prompted me to wonder about other forms of informatics and to what extent there can (should) be dialogue between these other disciplines?

In, Information and Knowledge needs of nurses in the 21st century (chapter 9), as an individual practitioner you are always situated (p.531) in a local nursing experience. I think this is where the model needs to be extended to facilitate the incorporation of local, global and glocal perspectives. Surely informatic's role as the latest technical means to communicate across a diaspora and it seems create a reverse diaspora through online communities and virtual worlds is worthy of a political stance? Global initiatives such as Health Information for All 2015 (what year is it next and still so much to do...) and other groups (maternal and infant care) need nursing's support and this extended information-informatics awareness (wisdom!) might also pay local and national dividends?

Chapter 10 is lengthy as befits legislative matters which nevertheless maintain the readable tone, clearly there is an ongoing evaluation by systems suppliers and users on the potential of the Cloud (Chapter 17). Chapter 11 was a nice surprise and the impact of which I have already referred to in e-portfolios. Individuals act as their own portal – p.187. This is a subject that (I hope) will occupy me for the next couple of years. The use of e-media by nurses for reflective commentary using web publishing tools is addressed very well. Having just ordered a second hand copy of Etienne Wenger’s book on communities of practice I find this discussed here:
In the future it is hoped that the use of communities of practice in nursing will grow beyond knowledge sharing and promote more knowledge discovery and sense making. p.189.
I’m not sure if e-portfolios have affected the EU populace with the rapidity and extent expected (by 2010), but there is a series of ongoing conferences dedicated to the cause. In the 1990s and early 2000s you could not miss the emphasis on benefits realization. If this concept has had its day what exactly happened? (There is no longer a need to prove the worth, potential of the computer at the bedside, nurses station.) We should still focus on outcomes as noted in several  chapters.

The sections also take on a practical – application focus across administration and nursing functions. Open source is further examined p.212. If SQL is mentioned would it help to acknowledge the development of noSQL approaches? Memory and processing power (for indexing) are less of a constraint on systems now. There is another challenge presented to editors: is 2004 really a ‘recent’ study? ‘Recent’ and its synonyms ‘currently’ need to be checked throughout the book and revised accordingly. The same applies to references to demographics and changes in nursing numbers (p.320-321). The trends in the numbers are established and remain, but perhaps there are more up-to-date sources? Throughout the book there are also case studies and pointers to research that provide practical and personal insights to the subject at hand.

While the context is nursing and informatics I think the discussion on ‘health literacy’ requires a critical review. It seems that health literacy may be being construed as synonymous with health technology literacy, computer and information literacy which are also noted in the text. There is admittedly a great deal of overlap.

‘Health literacy’ needs to be considered before a specific health problem arises – it is too late then. Health literacy does not mean, should not be equated with the deployment and use of e-tech applied to people with diabetes, coronary heart disease. Is this specific health education aimed at self-care, relapse prevention, staying well? Is health literacy concerned with positive health?

I’m sure the authors – editors are only too aware of this but this understanding of the wider context of ‘health literacy’ as a field of research and practice is not conveyed at present. I also don't necessarily see a wiki as a search tool, yes you can search a wiki but it is a type of repository and as such the effectiveness of a search must depend on the contributions made and the preceding searches. Perhaps a dedicated wiki could become a form e-grey literature?

A highpoint for this reviewer was to read: Learning is a multispatial function, … (p.406). It certainly is. The discussion on creating learning resources is an excellent introduction, especially on using the electronic health record as the learning resource.

In considering the future chapter 29 does not explicitly utilize the framework of knowledge. This may provide an opportunity to extend the framework to more readily integrate bio-psychosocial-political and spiritual perspectives through time. The framework of knowledge within informatics is a great resource. As mentioned this drew my interest to the book, in 1996 I sought to relate informatics concepts to nursing and mental health (redundancy, entropy.... see bibliography). Whatever the differences between the USA and UK nursing informatics the framework might benefit from a way to integrate context, specific concepts and practices, self-care, interprofessional education and wisdom.

This is a great book, one that is also courageous in its scope and execution. The third edition will be very well worth not just purchasing, but applying. Thanks again to Jones & Bartlett Learning for this copy.

MacKenzie, D. (2013). America's hidden epidemic of tropical diseases, New Scientist. 11 December 2013, 2947.
McGonigle, D., Mastrian, K.G. (2012) Nursing Informatics and the Foundation of Knowledge, Second Edition. Jones & Bartlett Learning, Burlington, MA.


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