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NURSING INFORMATICS
and the Foundation of
Knowledge
FOURTH EDITION

Dee McGonigle, PhD, RN, CNE, FAAN, ANEF
Director, Virtual Learning Experiences (VLE) and
Professor Graduate Program, Chamberlain College of
Nursing Member, Informatics and Technology Expert
Panel (ITEP) for the American Academy of Nursing

Kathleen Mastrian, PhD, RN
Associate Professor and Program Coordinator for
Nursing Pennsylvania State University, Shenango Sr.
Managing Editor, Online Journal of Nursing Informatics
(OJNI)

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Library of Congress Cataloging-in-Publication Data
Names: McGonigle, Dee, editor. | Mastrian, Kathleen
Garver, editor.
Title: Nursing informatics and the foundation of
knowledge/[edited by]
Dee McGonigle, Kathleen Mastrian.
Description: Fourth edition. | Burlington, MA: Jones &
Bartlett Learning,
[2018] | Includes bibliographical references and index.
Identifiers: LCCN 2016043838 | ISBN 9781284121247
(pbk.)
Subjects: | MESH: Nursing Informatics | Knowledge
Classification: LCC RT50.5 | NLM WY 26.5 | DDC
651.5/04261–dc23

LC record available at
https://lccn.loc.gov/2016043838

6048
Printed in the United States of America
21 20 19 18 17 10 9 8 7 6 5 4 3 2 1

The Pedagogy
Nursing Informatics and the Foundation of
Knowledge, Fourth Edition drives comprehension
through a variety of strategies geared toward meeting
the learning needs of students, while also generating
enthusiasm about the topic. This interactive approach
addresses diverse learning styles, making this the ideal
text to ensure mastery of key concepts. The
pedagogical aids that appear in most chapters include
the following:

Special Acknowledgments
We want to express our sincere appreciation to the
staff at Jones & Bartlett Learning, especially Amanda,
Christina, and Carolyn, for their continued
encouragement, assistance, and support during the
writing process and publication of our book.

Contents
Preface
Acknowledgments
Contributors

SECTION I: BUILDING BLOCKS OF
NURSING INFORMATICS

1 Nursing Science and the Foundation of
Knowledge
Dee McGonigle and Kathleen Mastrian
Introduction
Quality and Safety Education for Nurses
Summary
References

2 Introduction to Information, Information
Science, and Information Systems
Kathleen Mastrian and Dee McGonigle
Introduction
Information
Information Science
Information Processing
Information Science and the Foundation of
Knowledge
Introduction to Information Systems

Summary
References

3 Computer Science and the Foundation of
Knowledge Model
Dee McGonigle, Kathleen Mastrian, and
June Kaminski
Introduction
The Computer as a Tool for Managing
Information and Generating Knowledge
Components
What Is the Relationship of Computer Science
to Knowledge?
How Does the Computer Support Collaboration
and Information Exchange?
Cloud Computing
Looking to the Future
Summary
Working Wisdom
Application Scenario
References

4 Introduction to Cognitive Science and
Cognitive Informatics
Kathleen Mastrian and Dee McGonigle
Introduction
Cognitive Science
Sources of Knowledge
Nature of Knowledge

How Knowledge and Wisdom Are Used in
Decision Making
Cognitive Informatics
Cognitive Informatics and Nursing Practice
What Is AI?
Summary
References

5 Ethical Applications of Informatics
Dee McGonigle, Kathleen Mastrian, and
Nedra Farcus
Introduction
Ethics
Bioethics
Ethical Issues and Social Media
Ethical Dilemmas and Morals
Ethical Decision Making
Theoretical Approaches to Healthcare Ethics
Applying Ethics to Informatics
Case Analysis Demonstration
New Frontiers in Ethical Issues
Summary
References

SECTION II: PERSPECTIVES ON NURSING
INFORMATICS

6 History and Evolution of Nursing
Informatics

Kathleen Mastrian and Dee McGonigle
Introduction
The Evolution of a Specialty
What Is Nursing Informatics?
The DIKW Paradigm
Capturing and Codifying the Work of Nursing
The Nurse as a Knowledge Worker
The Future
Summary
References

7 Nursing Informatics as a Specialty
Dee McGonigle, Kathleen Mastrian, Julie A.
Kenney, and Ida Androwich Introduction
Nursing Contributions to Healthcare
Informatics
Scope and Standards
Nursing Informatics Roles
Specialty Education and Certification
Nursing Informatics Competencies
Rewards of NI Practice
NI Organizations and Journals
The Future of Nursing Informatics
Summary
References

8 Legislative Aspects of Nursing
Informatics: HITECH and HIPAA

Kathleen M. Gialanella, Kathleen Mastrian,
and Dee McGonigle Introduction
HIPAA Came First
Overview of the HITECH Act
How a National HIT Infrastructure Is Being
Developed
How the HITECH Act Changed HIPAA
Implications for Nursing Practice
Future Regulations
Summary
References

SECTION III: NURSING INFORMATICS
ADMINISTRATIVE
APPLICATIONS: PRECARE
AND CARE SUPPORT

9 Systems Development Life Cycle: Nursing
Informatics and Organizational Decision
Making
Dee McGonigle and Kathleen Mastrian
Introduction
Waterfall Model
Rapid Prototyping or Rapid Application
Development
Object-Oriented Systems Development
Dynamic System Development Method
Computer-Aided Software Engineering Tools

Open Source Software and Free/Open Source
Software
Interoperability
Summary
References

10 Administrative Information Systems
Marianela Zytkowski, Susan Paschke,
Kathleen Mastrian, and Dee McGonigle
Introduction
Types of Healthcare Organization Information
Systems
Communication Systems
Core Business Systems
Order Entry Systems
Patient Care Support Systems
Interoperability
Aggregating Patient and Organizational Data
Department Collaboration and Exchange of
Knowledge and Information
Summary
References

11 The Human–Technology Interface
Dee McGonigle, Kathleen Mastrian, and
Judith A. Effken Introduction
The Human–Technology Interface
The Human–Technology Interface Problem
Improving the Human–Technology Interface

A Framework for Evaluation
Future of the Human–Technology Interface
Summary
References

12 Electronic Security
Lisa Reeves Bertin, Kathleen Mastrian, and
Dee McGonigle Introduction
Securing Network Information
Authentication of Users
Threats to Security
Security Tools
Offsite Use of Portable Devices
Summary
References

13 Workflow and Beyond Meaningful Use
Dee McGonigle, Kathleen Mastrian, and
Denise Hammel-Jones Introduction
Workflow Analysis Purpose
Workflow and Technology
Workflow Analysis and Informatics Practice
Informatics as a Change Agent
Measuring the Results
Future Directions
Summary
References

SECTION IV: NURSING INFORMATICS
PRACTICE APPLICATIONS:
CARE DELIVERY

14 The Electronic Health Record and
Clinical Informatics
Emily B. Barey, Kathleen Mastrian, and Dee
McGonigle
Introduction
Setting the Stage
Components of Electronic Health Records
Advantages of Electronic Health Records
Standardized Terminology and the EHR
Ownership of Electronic Health Records
Flexibility and Expandability
Accountable Care Organizations and the EHR
The Future
Summary
References

15 Informatics Tools to Promote Patient
Safety and Quality Outcomes
Dee McGonigle and Kathleen Mastrian
Introduction
What Is a Culture of Safety?
Strategies for Developing a Safety Culture
Informatics Technologies for Patient Safety
Role of the Nurse Informaticist

Summary
References

16 Patient Engagement and Connected
Health
Kathleen Mastrian and Dee McGonigle
Introduction
Consumer Demand for Information
Health Literacy and Health Initiatives
Healthcare Organization Approaches to
Engagement
Promoting Health Literacy in School-Aged
Children
Supporting Use of the Internet for Health
Education
Future Directions for Engaging Patients
Summary
References

17 Using Informatics to Promote
Community/Population Health
Dee McGonigle, Kathleen Mastrian,
Margaret Ross Kraft, and Ida Androwich
Introduction
Core Public Health Functions
Community Health Risk Assessment: Tools for
Acquiring Knowledge
Processing Knowledge and Information to
Support Epidemiology and Monitoring Disease

Outbreaks
Applying Knowledge to Health Disaster
Planning and Preparation
Informatics Tools to Support Communication
and Dissemination
Using Feedback to Improve Responses and
Promote Readiness
Summary
References

18 Telenursing and Remote Access
Telehealth
Original contribution by Audrey Kinsella,
Kathleen Albright, Sheldon Prial, and
Schuyler F. Hoss; revised by Kathleen
Mastrian and Dee McGonigle Introduction
The Foundation of Knowledge Model and Home
Telehealth
Nursing Aspects of Telehealth
History of Telehealth
Driving Forces for Telehealth
Telehealth Care
Telenursing
Telehealth Patient Populations
Tools of Home Telehealth
Home Telehealth Software
Home Telehealth Practice and Protocols
Legal, Ethical, and Regulatory Issues

The Patient’s Role in Telehealth
Telehealth Research
Evolving Telehealth Models
Parting Thoughts for the Future and a View
Toward What the Future Holds
Summary
References

SECTION V: EDUCATION APPLICATIONS OF
NURSING INFORMATICS

19 Nursing Informatics and Nursing
Education
Heather E. McKinney, Sylvia DeSantis,
Kathleen Mastrian, and Dee McGonigle
Introduction: Nursing Education and the
Foundation of Knowledge Model
Knowledge Acquisition and Sharing
Evolution of Learning Management Systems
Delivery Modalities
Technology Tools Supporting Education
Internet-Based Tools
Promoting Active and Collaborative Learning
Knowledge Dissemination and Sharing
Exploring Information Fair Use and Copyright
Restrictions
The Future
Summary
References

20 Simulation, Game Mechanics, and Virtual
Worlds in Nursing Education
Dee McGonigle, Kathleen Mastrian, Brett
Bixler, and Nickolaus Miehl Introduction
Simulation in Nursing Informatics Education
Nursing Informatics Competencies in Nursing
Education
A Case for Simulation in Nursing Informatics
Education and Nursing Education
Incorporating EHRs into the Learning
Environment
Challenges and Opportunities
The Future of Simulation in Nursing
Informatics Education
Game Mechanics and Virtual World Simulation
for Nursing Education
Game Mechanics and Educational Games
Virtual Worlds in Education
Choosing Among Simulations, Educational
Games, and Virtual Worlds
The Future of Simulations, Games, and Virtual
Worlds in Nursing Education
Summary
References

SECTION VI: RESEARCH APPLICATIONS OF
NURSING INFORMATICS

21 Nursing Research: Data Collection,
Processing, and Analysis
Heather E. McKinney, Sylvia DeSantis,
Kathleen Mastrian, and Dee McGonigle
Introduction: Nursing Research and the
Foundation of Knowledge Model
Knowledge Generation Through Nursing
Research
Acquiring Previously Gained Knowledge
Through Internet and Library Holdings
Fair Use of Information and Sharing
Informatics Tools for Collecting Data and
Storage of Information
Tools for Processing Data and Data Analysis
The Future
Summary
References

22 Data Mining as a Research Tool
Dee McGonigle and Kathleen Mastrian
Introduction: Big Data, Data Mining, and
Knowledge Discovery
KDD and Research
Data Mining Concepts
Data Mining Techniques
Data Mining Models
Benefits of KDD
Data Mining and Electronic Health Records

Ethics of Data Mining
Summary
References

23 Translational Research: Generating
Evidence for Practice
Jennifer Bredemeyer, Ida Androwich, Dee
McGonigle, and Kathleen Mastrian
Introduction
Clarification of Terms
History of Evidence-Based Practice
Evidence
Bridging the Gap Between Research and
Practice
Barriers to and Facilitators of Evidence-Based
Practice
The Role of Informatics
Developing EBP Guidelines
Meta-Analysis and Generation of Knowledge
The Future
Summary
References

24 Bioinformatics, Biomedical Informatics,
and Computational Biology
Dee McGonigle and Kathleen Mastrian
Introduction
Bioinformatics, Biomedical Informatics, and
Computational Biology Defined

Why Are Bioinformatics and Biomedical
Informatics So Important?
What Does the Future Hold?
Summary
References

SECTION VII: IMAGINING THE FUTURE OF
NURSING INFORMATICS

25 The Art of Caring in Technology-Laden
Environments
Kathleen Mastrian and Dee McGonigle
Introduction
Caring Theories
Presence
Strategies for Enhancing Caring Presence
Reflective Practice
Summary
References

26 Nursing Informatics and the Foundation
of Knowledge
Dee McGonigle and Kathleen Mastrian
Introduction
Foundation of Knowledge Revisited
The Nature of Knowledge
Knowledge Use in Practice
Characteristics of Knowledge Workers
Knowledge Management in Organizations

Managing Knowledge Across Disciplines
The Learning Healthcare System
Summary
References

Abbreviations

Glossary

Index

Preface
The idea for this text originated with the development
of nursing informatics (NI) classes, the publication of
articles related to technology-based education, and the
creation of the Online Journal of Nursing Informatics
(OJNI), which Dee McGonigle cofounded with Renee
Eggers. Like most nurse informaticists, we fell into the
specialty; our love affair with technology and gadgets
and our willingness to be the first to try new things
helped to hook us into the specialty of informatics. The
rapid evolution of technology and its transformation of
the ways of nursing prompted us to try to capture the
essence of NI in a text.

As we were developing the first edition, we realized
that we could not possibly know all there is to know
about informatics and the way in which it supports
nursing practice, education, administration, and
research. We also knew that our faculty roles
constrained our opportunities for exposure to changes
in this rapidly evolving field. Therefore, we developed a
tentative outline and a working model of the theoretical
framework for the text and invited participation from
informatics experts and specialists around the world.
We were pleased with the enthusiastic responses we
received from some of those invited contributors and a

few volunteers who heard about the text and asked to
participate in their particular area of expertise.

In the second edition, we invited the original
contributors to revise and update their chapters. Not
everyone chose to participate in the second edition, so
we revised several of the chapters using the original
work as a springboard. The revisions to the text were
guided by the contributors’ growing informatics
expertise and the reviews provided by textbook
adopters. In the revisions, we sought to do the
following:

Expand the audience focus to include nursing
students from BS through DNP programs as well as
nurses thrust into informatics roles in clinical
agencies.
Include, whenever possible, an attention-grabbing
case scenario as an introduction or an illustrative
case scenario demonstrating why the topic is
important.
Include important research findings related to the
topic. Many chapters have research briefs
presented in text boxes to encourage the reader to
access current research.
Focus on cutting-edge innovations, meaningful use,
and patient safety as appropriate to each topic.
Include a paragraph describing what the future
holds for each topic.

New chapters that were added to the second edition
included those focusing on technology and patient
safety, system development life cycle, workflow
analysis, gaming, simulation, and bioinformatics.

In the third edition, we reviewed and updated all of the
chapters, reordered some chapters for better content
flow, eliminated duplicated content, split the education
and research content into two sections, integrated
social media content, and added two new chapters:
Data Mining as a Research Tool and The Art of Caring
in Technology-Laden Environments.

In this fourth edition, we reviewed and updated all of
the chapters based on technological advancements
and changes to the healthcare arena, including
reimbursement mechanisms for services. We have
pared this edition down to 26 chapters from the
previous edition’s 29; one chapter each was deleted
from Sections II, V, and VII. Section I includes
updates to the same five chapters on the building
blocks of nursing informatics, with extensive changes
to Chapter 3, Computer Science and the Foundation of
Knowledge Model. To improve flow, we combined
content. In Section II, the previous four chapters were
narrowed to three. New Chapters 6, History and
Evolution of Nursing Informatics and 7, Nursing
Informatics as a Specialty, were developed and
appropriate material from previous Chapters 6, 7, and
8 were assimilated. This section ends with an updated

Chapter 8, Legislative Aspects of Nursing Informatics:
HITECH and HIPAA (formerly Chapter 9). Section III
contains the same five chapters, although all were
updated and Chapter 13, Workflow and Beyond
Meaningful Use (formerly Chapter 14) now reflects the
payment models and reimbursement issues that we
are adjusting to after meaningful use has gone away.
Section IV contains the same five chapters with
updated content and some name changes to reflect the
current status of informatics and healthcare. Chapter
15 was renamed to Informatics Tools to Promote
Patient Safety and Quality Outcomes, and Chapter 16
has been changed to Patient Engagement and
Connected Health. Section V went from three chapters
to two chapters: Chapter 19 (formerly Chapter 20)
was updated, while the new Chapter 20, Simulation,
Game Mechanics, and Virtual Worlds in Nursing
Education, had content from former Chapters 21 and
22 integrated during its development. Section VI was
renamed to Research Applications of Nursing
Informatics. It still has the same four chapters, which
have been updated, but the first chapter in this section,
21, was renamed to reflect nursing research; its new
name is Nursing Research: Data Collection,
Processing, and Analysis. Section VII went from three
chapters to two chapters. Because emerging
technologies are discussed throughout the text, the
chapter focusing specifically on that was removed. The
two chapters that remain are Chapter 25, The Art of
Caring in Technology-Laden Environments, and the

new Chapter 26, Nursing Informatics and Knowledge
Management. In addition, the ancillary materials have
been updated and enhanced to include competency-
based self-assessments and mapping the content to
the current NI standards.

We believe that this text provides a comprehensive
elucidation of this exciting field. Its theoretical
underpinning is the Foundation of Knowledge model.
This model is introduced in its entirety in the first
chapter (Nursing Science and the Foundation of
Knowledge), which discusses nursing science and its
relationship to NI. We believe that humans are organic
information systems that are constantly acquiring,
processing, and generating information or knowledge
in both their professional and personal lives. It is their
high degree of knowledge that characterizes humans
as extremely intelligent, organic machines. Individuals
have the ability to manage knowledge—an ability that
is learned and honed from birth. We make our way
through life interacting with our environment and being
inundated with information and knowledge. We
experience our environment and learn by acquiring,
processing, generating, and disseminating knowledge.
As we interact in our environment, we acquire
knowledge that we must process. This processing
effort causes us to redefine and restructure our
knowledge base and generate new knowledge. We
then share (disseminate) this new knowledge and
receive feedback from others. The dissemination and

feedback initiate this cycle of knowledge over again, as
we acquire, process, generate, and disseminate the
knowledge gained from sharing and re-exploring our
own knowledge base. As others respond to our
knowledge dissemination and we acquire new
knowledge, we engage in rethinking and reflecting on
our knowledge, processing, generating, and then
disseminating anew.

The purpose of this text is to provide a set of practical
and powerful tools to ensure that the reader gains an
understanding of NI and moves from information
through knowledge to wisdom. Defining the demands
of nurses and providing tools to help them survive and
succeed in the Knowledge Era remains a major
challenge. Exposing nursing students and nurses to
the principles and tools used in NI helps to prepare
them to meet the challenge of practicing nursing in the
Knowledge Era while striving to improve patient care at
all levels.

The text provides a comprehensive framework that
embraces knowledge so that readers can develop their
knowledge repositories and the wisdom necessary to
act on and apply that knowledge. The text is divided
into seven sections.

Section I, Building Blocks of Nursing Informatics,
covers the building blocks of NI: nursing science,
information science, computer science, cognitive

science, and the ethical management of
information.
Section II, Perspectives on Nursing Informatics,
provides readers with a look at various viewpoints
on NI and NI practice as described by experts in the
field.
Section III, Nursing Informatics Administrative
Applications: Precare and Care Support, covers
important functions of administrative applications of
NI.
Section IV, Nursing Informatics Practice
Applications: Care Delivery, covers healthcare
delivery applications including electronic health
records (EHRs), clinical information systems,
telehealth, patient safety, patient and community
education, and care management.
Section V, Education Applications of Nursing
Informatics, presents subject matter on how
informatics supports nursing education.
Section VI, Research Applications of Nursing
Informatics, covers informatics tools to support
nursing research, including data mining and
bioinformatics.
Section VII, Imagining the Future of Nursing
Informatics, focuses on the future of NI,
emphasizes the need to preserve caring functions
in technology-laden environments, and reviews the
relationship of nursing informatics to organizational
knowledge management.

The introduction to each section explains the
relationship between the content of that section and the
Foundation of Knowledge model. This text places the
material within the context of knowledge acquisition,
processing, generation, and dissemination. It serves
both nursing students (BS to DNP/PhD) and
professionals who need to understand, use, and
evaluate NI knowledge. As nursing professors, our
major responsibility is to prepare the practitioners and
leaders in the field. Because NI permeates the entire
scope of nursing (practice, administration, education,
and research), nursing education curricula must
include NI. Our primary objective is to develop the most
comprehensive and user-friendly NI text on the market
to prepare nurses for current and future practice
challenges. In particular, this text provides a solid
groundwork from which to integrate NI into practice,
education, administration, and research.

Goals of this text are as follows:

Impart core NI principles that should be familiar to
every nurse and nursing student
Help the reader understand knowledge and how it
is acquired, processed, generated, and
disseminated
Explore the changing role of NI professionals
Demonstrate the value of the NI discipline as an
attractive field of specialization

Meeting these goals will help nurses and nursing
students understand and use fundamental NI principles
so that they efficiently and effectively function as
current and future nursing professionals to enhance the
nursing profession and improve the quality of health
care. The overall vision, framework, and pedagogy of
this text offer benefits to readers by highlighting
established principles while drawing out new ones that
continue to emerge as nursing and technology evolve.

Acknowledgments
We are deeply grateful to the contributors who
provided this text with a richness and diversity of
content that we could not have captured alone. Joan
Humphrey provided social media content integrated
throughout the text. We especially wish to
acknowledge the superior work of Alicia Mastrian,
graphic designer of the Foundation of Knowledge
model, which serves as the theoretical framework on
which this text is anchored. We could never have
completed this project without the dedicated and
patient efforts of the Jones & Bartlett Learning staff,
especially Amanda Martin, Emma Huggard, and
Christina Freitas, all of whom fielded our questions and
concerns in a very professional, respectful, and timely
manner.

Dee acknowledges the undying love, support, patience,
and continued encouragement of her best friend and
husband, Craig, and her son, Craig, who has made her
so very proud. She sincerely thanks her cousins
Camille, Glenn, Mary Jane, and Sonny, and her dear
friends for their support and encouragement, especially
Renee.

Kathy acknowledges the loving support of her family:
husband Chip; children Ben and Alicia; sisters Carol
and Sue; and parents Robert and Rosalie Garver. She
dedicates her work on this edition to her dad, Robert,
who died September 17, 2016. Kathy also
acknowledges those friends who understand the
importance of validation, especially Katie, Lisa, Kathy,
Maureen, Anne, Barbara, and Sally.

Authors’ Note
This text provides an overview of nursing informatics
from the perspective of diverse experts in the field, with
a focus on nursing informatics and the Foundation of
Knowledge model. We want our readers and students
to focus on the relationship of knowledge to informatics
and to embrace and maintain the caring functions of
nursing—messages all too often lost in the romance
with technology. We hope you enjoy the text!

Contributors
Ida Androwich, PhD, RN, BC, FAAN
Loyola University Chicago
School of Nursing
Maywood, IL

Emily Barey, MSN, RN
Director of Nursing Informatics
Epic Systems Corporation
Madison, WI

Lisa Reeves Bertin, BS, EMBA
Pennsylvania State University
Sharon, PA

Brett Bixler, PhD
Pennsylvania State University
University Park, PA

Jennifer Bredemeyer, RN
Loyola University Chicago
School of Nursing
Skokie, IL

Steven Brewer, PhD
Assistant Professor, Administration of Justice

Pennsylvania State University
Sharon, PA

Sylvia M. DeSantis, MA
Pennsylvania State University
University Park, PA

Judith Effken, PhD, RN, FACMI
University of Arizona
College of Nursing
Tucson, AZ

Nedra Farcus, MSN, RN
Retired from Pennsylvania State University, Altoona
Altoona, PA

Kathleen M. Gialanella, JD, RN, LLM
Law Offices
Westfield, NJ
Associate Adjunct Professor
Teachers College, Columbia University
New York, NY
Adjunct Professor
Seton Hall University, College of Nursing & School
of Law
South Orange & Newark, NJ

Denise Hammel-Jones, MSN, RN-BC, CLSSBB
Greencastle Associates Consulting
Malvern, PA

Nicholas Hardiker, PhD, RN
Senior Research Fellow
University of Salford
School of Nursing & Midwifery
Salford, UK

Glenn Johnson, MLS
Pennsylvania State University
University Park, PA

June Kaminski, MSN, RN
Kwantlen University College
Surrey, British Columbia, Canada

Julie Kenney, MSN, RNC-OB
Clinical Analyst
Advocate Health Care
Oak Brook, IL

Margaret Ross Kraft, PhD, RN
Loyola University Chicago
School of Nursing
Maywood, IL

Wendy L. Mahan, PhD, CRC, LPC
Pennsylvania State University
University Park, PA

Heather McKinney, PhD

Pennsylvania State University
University Park, PA

Nickolaus Miehl, MSN, RN
Oregon Health Sciences University
Monmouth, OR

Lynn M. Nagle, PhD, RN
Assistant Professor
University of Toronto
Toronto, Ontario, Canada

Ramona Nelson, PhD, RN-BC, FAAN, ANEF
Professor Emerita, Slippery Rock University
President, Ramona Nelson Consulting
Pittsburgh, PA

Nancy Staggers, PhD, RN, FAAN
Professor, Informatics
University of Maryland
Baltimore, MD

Jeff Swain
Instructional Designer
Pennsylvania State University
University Park, PA

Denise D. Tyler, MSN/MBA, RN-BC
Implementation Specialist
Healthcare Provider, Consulting

ACS, a Xerox Company
Dearborn, MI
The Editors also acknowledge the work of the
following first edition contributors (original
contributions edited by McGonigle and Mastrian for
second edition):

Kathleen Albright, BA, RN
Strategic Account Manager at GE Healthcare
Philadelphia, PA

Schuyler F. Hoss, BA
Northwest Healthcare Management
Vancouver, WA

Audrey Kinsella, MA, MS
Information for Tomorrow
Telehealth Planning Services
Asheville, NC

Peter J. Murray, PhD, RN, FBCS
Coachman’s Cottage
Nocton, Lincoln, UK

Susan M. Paschke, MSN, RN
The Cleveland Clinic
Cleveland, OH

Sheldon Prial, RPH, BS Pharmacy
Sheldon Prial Consultance

Melbourne, FL

Jackie Ritzko
Pennsylvania State University
Hazelton, PA

Marianela Zytkowsi, MSN, RN
The Cleveland Clinic
Cleveland, OH

SECTION I: Building
Blocks of Nursing
Informatics

Chapter 1 Nursing Science and the Foundation
of Knowledge

Chapter 2 Introduction to Information,
Information Science, and Information Systems

Chapter 3 Computer Science and the
Foundation of Knowledge Model

Chapter 4 Introduction to Cognitive Science and
Cognitive Informatics

Chapter 5 Ethical Applications of Informatics

Nursing professionals are information-dependent
knowledge workers. As health care continues to evolve
in an increasingly competitive information marketplace,
professionals—that is, the knowledge workers—must
be well prepared to make significant contributions by
harnessing appropriate and timely information. Nursing
informatics (NI), a product of the scientific synthesis of
information in nursing, encompasses concepts from
computer science, cognitive science, information
science, and nursing science. NI continues to evolve

as more and more professionals access, use, and
develop the information, computer, and cognitive
sciences necessary to advance nursing science for the
betterment of patients and the profession. Regardless
of their future roles in the healthcare milieu, it is clear
that nurses need to understand the ethical application
of computer, information, and cognitive sciences to
advance nursing science.

To implement NI, one must view it from the perspective
of both the current healthcare delivery system and
specific, individual organizational needs, while
anticipating and creating future applications in both the
healthcare system and the nursing profession. Nursing
professionals should be expected to discover
opportunities to use NI, participate in the design of
solutions, and be challenged to identify, develop,
evaluate, modify, and enhance applications to improve
patient care. This text is designed to provide the reader
with the information and knowledge needed to meet
this expectation.

Section I presents an overview of the building blocks of
NI: nursing, information, computer, and cognitive
sciences. Also included in this section is a chapter on
ethical applications of healthcare informatics. This
section lays the foundation for the remainder of the
book.

The Nursing Science and the Foundation of Knowledge

chapter describes nursing science and introduces the
Foundation of Knowledge model as the conceptual
framework for the book. In this chapter, a clinical case
scenario is used to illustrate the concepts central to
nursing science. A definition of nursing science is also
derived from the American Nurses Association’s
definition of nursing. Nursing science is the ethical
application of knowledge acquired through education,
research, and practice to provide services and
interventions to patients to maintain, enhance, or
restore their health, and to acquire, process, generate,
and disseminate nursing knowledge to advance the
nursing profession. Information is a central concept
and health care’s most valuable resource. Information
science and systems, together with computers, are
constantly changing the way healthcare organizations
conduct their business. This will continue to evolve.

To prepare for these innovations, the reader must
understand fundamental information and computer
concepts, covered in the Introduction to Information,
Information Science, and Information Systems and
Computer Science and the Foundation of Knowledge
Model chapters, respectively. Information science deals
with the interchange (or flow) and scaffolding (or
structure) of information and involves the application of
information tools for solutions to patient care and
business problems in health care. To be able to use
and synthesize information effectively, an individual
must be able to obtain, perceive, process, synthesize,

comprehend, convey, and manage the information.
Computer science deals with understanding the
development, design, structure, and relationship of
computer hardware and software. This science offers
extremely valuable tools that, if used skillfully, can
facilitate the acquisition and manipulation of data and
information by nurses, who can then synthesize these
resources into an ever-evolving knowledge and
wisdom base. This not only facilitates professional
development and the ability to apply evidence-based
practice decisions within nursing care, but, if the results
are disseminated and shared, can also advance the
profession’s knowledge base. The development of
knowledge tools, such as the automation of decision
making and strides in artificial intelligence, has altered
the understanding of knowledge and its representation.
The ability to structure knowledge electronically
facilitates the ability to share knowledge structures and
enhance collective knowledge.

As discussed in the Introduction to Cognitive Science
and Cognitive Informatics chapter, cognitive science
deals with how the human mind functions. This science
encompasses how people think, understand,
remember, synthesize, and access stored information
and knowledge. The nature of knowledge, including
how it is developed, used, modified, and shared,
provides the basis for continued learning and
intellectual growth.

The Ethical Applications of Informatics chapter focuses
on ethical issues associated with managing private
information with technology and provides a framework
for analyzing ethical issues and supporting ethical
decision making.

The material within this book is placed within the
context of the Foundation of Knowledge model (shown
in Figure I-1 and periodically throughout the book, but
more fully introduced and explained in the Nursing
Science and the Foundation of Knowledge chapter).
The Foundation of Knowledge model is used
throughout the text to illustrate how knowledge is used
to meet the needs of healthcare delivery systems,
organizations, patients, and nurses. It is through
interaction with these building blocks—the theories,
architecture, and tools—that one acquires the bits and
pieces of data necessary, processes these into
information, and generates and disseminates the
resulting knowledge. Through this dynamic exchange,
which includes feedback, individuals continue the
interaction and use of these sciences to input or
acquire, process, and output or disseminate generated
knowledge. Humans experience their environment and
learn by acquiring, processing, generating, and
disseminating knowledge. When they then share
(disseminate) this new knowledge and receive
feedback on the knowledge they have shared, the
feedback initiates the cycle of knowledge all over
again. As individuals acquire, process, generate, and

disseminate knowledge, they are motivated to share,
rethink, and explore their own knowledge base. This
complex process is captured in the Foundation of
Knowledge model. Throughout the chapters in the
Building Blocks of Nursing Informatics section, readers
are challenged to think about how the model can help
them to understand the ways in which they acquire,
process, generate, disseminate, and then receive and
process feedback on their new knowledge of the
building blocks of NI.

Figure I-1 Foundation of Knowledge Model

Designed by Alicia Mastrian

CHAPTER 1: Nursing
Science and the
Foundation of
Knowledge

Dee McGonigle and Kathleen Mastrian

Objectives
1. Define nursing science and its

relationship to various nursing roles and
nursing informatics.

2. Introduce the Foundation of Knowledge
model as the organizing conceptual
framework for the text.

3. Explain the relationships among
knowledge acquisition, knowledge
processing, knowledge generation,
knowledge dissemination, and wisdom.

Key Terms
» Borrowed theory

» Building blocks

» Clinical databases

» Clinical practice guidelines

» Conceptual framework

» Data

» Data mining

» Evidence

» Feedback

» Foundation of Knowledge model

» Information

» Knowledge

» Knowledge acquisition

» Knowledge dissemination

» Knowledge generation

» Knowledge processing

» Knowledge worker

» Nursing informatics

» Nursing science

» Nursing theory

» Relational database

» Transparent wisdom

Introduction
Nursing informatics has been traditionally defined as
a specialty that integrates nursing science, computer
science, and information science to manage and
communicate data, information, knowledge, and
wisdom in nursing practice. This chapter focuses on
nursing science as one of the building blocks of
nursing informatics. As depicted in Figure 1-1, the
traditional definition of nursing informatics is extended
to include cognitive science. The Foundation of
Knowledge model is also introduced as the organizing
conceptual framework of this text, and the model is
tied to nursing science and the practice of nursing
informatics. To lay the groundwork for this discussion,
consider the following patient scenario:

Tom H. is a registered nurse who works
in a very busy metropolitan hospital
emergency room. He has just admitted a
79-year-old man whose wife brought him
to the hospital because he is having
trouble breathing. Tom immediately clips

a pulse oximeter to the patient’s finger
and performs a very quick assessment of
the patient’s other vital signs. He
discovers a rapid pulse rate and a
decreased oxygen saturation level in
addition to the rapid and labored
breathing. Tom determines that the
patient is not in immediate danger and
that he does not require intubation. Tom
focuses his initial attention on easing the
patient’s labored breathing by elevating
the head of the bed and initiating oxygen
treatment; he then hooks the patient up to
a heart monitor. Tom continues to assess
the patient’s breathing status as he
performs a head-to-toe assessment of
the patient that leads to the nursing
diagnoses and additional interventions
necessary to provide comprehensive care
to this patient.

Consider Tom’s actions and how and why he
intervened as he did. Tom relied on the immediate data
and information that he acquired during his initial
rapid assessment to deliver appropriate care to his
patient. Tom also used technology (a pulse oximeter
and a heart monitor) to assist with and support the
delivery of care. What is not immediately apparent, and
some would argue is transparent (done without

conscious thought), is the fact that during the rapid
assessment, Tom reached into his knowledge base of
previous learning and experiences to direct his care, so
that he could act with transparent wisdom. He used
both nursing theory and borrowed theory to inform
his practice. Tom certainly used nursing process
theory, and he may have also used one of several
other nursing theories, such as Rogers’s science of
unitary human beings, Orem’s theory of self-care
deficit, or Roy’s adaptation theory. In addition, Tom
may have applied his knowledge from some of the
basic sciences, such as anatomy, physiology,
psychology, and chemistry, as he determined the
patient’s immediate needs. Information from Maslow’s
hierarchy of needs, Lazarus’s transaction model of
stress and coping, and the health belief model may
have also helped Tom practice professional nursing.
He gathered data, and then analyzed and interpreted
those data to form a conclusion—the essence of
science. Tom has illustrated the practical aspects of
nursing science.

The American Nurses Association (2016) defines
nursing in this way: “Nursing is the protection,
promotion, and optimization of health and abilities,
prevention of illness and injury, facilitation of healing,
alleviation of suffering through the diagnosis and
treatment of human response, and advocacy in the
care of individuals, families, groups, communities, and
populations” (para. 1). Thus the focus of nursing is on

human responses to actual or potential health
problems and advocacy for various clients. These
human responses are varied and may change over
time in a single case. Nurses must possess the
technical skills to manage equipment and perform
procedures, the interpersonal skills to interact
appropriately with people, and the cognitive skills to
observe, recognize, and collect data; analyze and
interpret data; and reach a reasonable conclusion that
forms the basis of a decision. At the heart of all of
these skills lies the management of data and
information. This definition of nursing science focuses
on the ethical application of knowledge acquired
through education, research, and practice to provide
services and interventions to patients to maintain,
enhance, or restore their health and to acquire,
process, generate, and disseminate nursing knowledge
to advance the nursing profession.

Figure 1-1 Building Blocks of Nursing Informatics

Nursing is an information-intensive profession. The
steps of using information, applying knowledge to a
problem, and acting with wisdom form the basis of
nursing practice science. Information is composed of
data that were processed using knowledge. For
information to be valuable, it must be accessible,
accurate, timely, complete, cost-effective, flexible,
reliable, relevant, simple, verifiable, and secure.
Knowledge is the awareness and understanding of a
set of information and ways that information can be

made useful to support a specific task or arrive at a
decision. In the case scenario, Tom used accessible,
accurate, timely, relevant, and verifiable data and
information. He compared that data and information to
his knowledge base of previous experiences to
determine which data and information were relevant to
the current case. By applying his previous knowledge
to data, he converted those data into information, and
information into new knowledge—that is, an
understanding of which nursing interventions were
appropriate in this case. Thus information is data made
functional through the application of knowledge.

Humans acquire data and information in bits and
pieces and then transform the information into
knowledge. The information-processing functions of the
brain are frequently compared to those of a computer,
and vice versa (see a discussion of cognitive
informatics for more information). Humans can be
thought of as organic information systems that are
constantly acquiring, processing, and generating
information or knowledge in their professional and
personal lives. They have an amazing ability to
manage knowledge. This ability is learned and honed
from birth as individuals make their way through life
interacting with the environment and being inundated
with data and information. Each person experiences
the environment and learns by acquiring, processing,
generating, and disseminating knowledge.

Tom, for example, acquired knowledge in his basic
nursing education program and continues to build his
foundation of knowledge by engaging in such activities
as reading nursing research and theory articles,
attending continuing education programs, consulting
with expert colleagues, and using clinical databases
and clinical practice guidelines. As he interacts in
the environment, he acquires knowledge that must be
processed. This processing effort causes him to
redefine and restructure his knowledge base and
generate new knowledge. Tom can then share
(disseminate) this new knowledge with colleagues, and
he may receive feedback on the knowledge that he
shares. This dissemination and feedback builds the
knowledge foundation anew as Tom acquires,
processes, generates, and disseminates new
knowledge as a result of his interactions. As others
respond to his knowledge dissemination and he
acquires yet more knowledge, he is engaged to rethink,
reflect on, and re-explore his knowledge acquisition,
leading to further processing, generating, and then
disseminating knowledge. This ongoing process is
captured in the Foundation of Knowledge model, which
is used as an organizing framework for this text.

At its base, the model contains bits, bytes (a computer
term used to quantify data), data, and information in a
random representation. Growing out of the base are
separate cones of light that expand as they reflect
upward; these cones represent knowledge acquisition,

knowledge generation, and knowledge dissemination.
At the intersection of the cones and forming a new
cone is knowledge processing. Encircling and cutting
through the knowledge cones is feedback that acts on
and may transform any or all aspects of knowledge
represented by the cones. One should imagine the
model as a dynamic figure in which the cones of light
and the feedback rotate and interact rather than remain
static. Knowledge acquisition, knowledge generation,
knowledge dissemination, knowledge processing, and
feedback are constantly evolving for nurse scientists.
The transparent effect of the cones is deliberate and is
intended to suggest that as knowledge grows and
expands, its use becomes more transparent—a person
uses this knowledge during practice without even being
consciously aware of which aspect of knowledge is
being used at any given moment.

Experienced nurses, thinking back to their novice
years, may recall feeling like their head was filled with
bits of data and information that did not form any type
of cohesive whole. As the model depicts, the
processing of knowledge begins a bit later (imagine a
timeline applied vertically) with early experiences on
the bottom and expertise growing as the processing of
knowledge ensues. Early on in nurses’ education,
conscious attention is focused mainly on knowledge
acquisition, and beginning nurses depend on their
instructors and others to process, generate, and
disseminate knowledge. As nurses become more

comfortable with the science of nursing, they begin to
take over some of the other Foundation of Knowledge
functions. However, to keep up with the explosion of
information in nursing and health care, they must
continue to rely on the knowledge generation of
nursing theorists and researchers and the
dissemination of their work. In this sense, nurses are
committed to lifelong learning and the use of
knowledge in the practice of nursing science.

The Foundation of Knowledge model (Figure 1-2)
permeates this text, reflecting the understanding that
knowledge is a powerful tool and that nurses focus on
information as a key building block of knowledge. The
application of the model is described to help the reader
understand and appreciate the foundation of
knowledge in nursing science and see how it applies to
nursing informatics. All of the various nursing roles
(practice, administration, education, research, and
informatics) involve the science of nursing. Nurses are
knowledge workers, working with information and
generating information and knowledge as a product.
They are knowledge acquirers, providing convenient
and efficient means of capturing and storing
knowledge. They are knowledge users, meaning
individuals or groups who benefit from valuable, viable
knowledge. Nurses are knowledge engineers,
designing, developing, implementing, and maintaining
knowledge. They are knowledge managers, capturing
and processing collective expertise and distributing it

where it can create the largest benefit. Finally, they are
knowledge developers and generators, changing and
evolving knowledge based on the tasks at hand and
the information available.

In the case scenario, at first glance one might label
Tom as a knowledge worker, a knowledge acquirer,
and a knowledge user. However, stopping here might
sell Tom short in his practice of nursing science.
Although he acquired and used knowledge to help him
achieve his work, he also processed the data and
information he collected to develop a nursing diagnosis
and a plan of care. The knowledge stores Tom used to
develop and glean knowledge from valuable
information are generative (having the ability to
originate and produce or generate) in nature. For
example, Tom may have learned something new about
his patient’s culture from the patient or his wife that he
will file away in the knowledge repository of his mind to
be used in another similar situation. As he compares
this new cultural information to what he already knows,
he may gain insight into the effect of culture on a
patient’s response to illness. In this sense, Tom is a
knowledge generator. If he shares this newly acquired
knowledge with another practitioner, and as he records
his observations and his conclusions, he is then
disseminating knowledge. Tom also uses feedback
from the various technologies he has applied to
monitor his patient’s status. In addition, he may rely on
feedback from laboratory reports or even other

practitioners to help him rethink, revise, and apply the
knowledge about this patient that he is generating.

To have ongoing value, knowledge must be viable.
Knowledge viability refers to applications (most
technology based) that offer easily accessible,
accurate, and timely information obtained from a
variety of resources and methods and presented in a
manner so as to provide the necessary elements to
generate new knowledge. In the case scenario, Tom
may have felt the need to consult an electronic
database or a clinical guidelines repository that he has
downloaded on his tablet or smartphone, or that
resides in the emergency room’s networked computer
system, to assist him in the development of a
comprehensive care plan for his patient. In this way,
Tom uses technology and evidence to support and
inform his practice. It is also possible in this scenario
that an alert might appear in the patient’s electronic
health record or the clinical information system (CIS)
reminding Tom to ask about influenza and pneumonia
vaccines. Clinical information technologies that support
and inform nursing practice and nursing administration
are an important part of nursing informatics.

Figure 1-2 Foundation of Knowledge Model

Designed by Alicia Mastrian

This text provides a framework that embraces
knowledge so that readers can develop the wisdom
necessary to apply what they have learned. Wisdom is
the application of knowledge to an appropriate
situation. In the practice of nursing science, one
expects actions to be directed by wisdom. Wisdom
uses knowledge and experience to heighten common
sense and insight to exercise sound judgment in
practical matters. It is developed through knowledge,
experience, insight, and reflection. Wisdom is
sometimes thought of as the highest form of common
sense, resulting from accumulated knowledge or
erudition (deep, thorough learning) or enlightenment

(education that results in understanding and the
dissemination of knowledge). It is the ability to apply
valuable and viable knowledge, experience,
understanding, and insight while being prudent and
sensible. Knowledge and wisdom are not synonymous:
Knowledge abounds with others’ thoughts and
information, whereas wisdom is focused on one’s own
mind and the synthesis of experience, insight,
understanding, and knowledge. Wisdom has been
called the foundation of the art of nursing.

Some nursing roles might be viewed as more focused
on some aspects rather than other aspects of the
foundation of knowledge. For example, some might
argue that nurse educators are primarily knowledge
disseminators and that nurse researchers are
knowledge generators. Although the more frequent
output of their efforts can certainly be viewed in this
way, it is important to realize that nurses use all of the
aspects of the Foundation of Knowledge model
regardless of their area of practice. For nurse
educators to be effective, they must be in the habit of
constantly building and rebuilding their foundation of
knowledge about nursing science. In addition, as they
develop and implement curricular innovations, they
must evaluate the effectiveness of those changes. In
some cases, they use formal research techniques to
achieve this goal and, therefore, generate knowledge
about the best and most effective teaching strategies.
Similarly, nurse researchers must acquire and process

new knowledge as they design and conduct their
research studies. All nurses have the opportunity to be
involved in the formal dissemination of knowledge via
their participation in professional conferences, either as
presenters or as attendees. In addition, some nurses
disseminate knowledge by formal publication of their
ideas. In the cases of conference presentation and
publication, nurses may receive feedback that
stimulates rethinking about the knowledge they have
generated and disseminated, in turn prompting them to
acquire and process data and information anew.

All nurses, regardless of their practice arena, must use
informatics and technology to inform and support that
practice. The case scenario discussed Tom’s use of
various monitoring devices that provide feedback on
the physiologic status of the patient. It was also
suggested that Tom might consult a clinical database
or nursing practice guidelines residing on a tablet or
smartphone, in the cloud (a virtual information storage
system), or on a clinical agency network as he
develops an appropriate plan of action for his nursing
interventions. Perhaps the CIS in the agency supports
the collection of data about patients in a relational
database, providing an opportunity for data mining by
nursing administrators or nurse researchers. In this
way, administrators and researchers can glean
information about best practices and determine which
improvements are necessary to deliver the best and

most effective nursing care (Swan, Lang, & McGinley,
2004).

The future of nursing science and nursing informatics is
closely associated with nursing education and nursing
research. Skiba (2007) suggested that techno-savvy
and well-informed faculty who can demonstrate the
appropriate use of technologies to enhance the
delivery of nursing care are needed. Along those lines,
Whitman-Price, Kennedy, and Godwin (2012)
conducted research among senior nursing students to
determine perceptions of personal phone use to
access healthcare information during clinical. Their
study indicated that ready access to electronic
resources enhanced clinical decision making and
confidence in patient care. Girard (2007) discussed
cutting-edge operating room technologies, such as
nanosurgery using nanorobots, smart fabrics that aid in
patient assessment during surgery, biopharmacy
techniques for the safe and effective delivery of
anesthesia, and virtual reality training. She made an
extremely provocative point about nursing education:
“Educators will need to expand their knowledge and
teach for the future and not the past. They must take
heed that the old tried-and-true nursing education
methods and curriculum that has lasted 100 years will
have to change, and that change will be mandated for
all areas of nursing” (p. 353). Bassendowski (2007)
specifically addressed the potential for the generation
of knowledge in educational endeavors as faculty apply

new technologies to teaching and the focus shifts away
from individual to group instruction that promotes
sharing and processing of knowledge.

Several key national groups continue to promote the
inclusion of informatics content in nursing education
programs. These initiatives include the Vision Series by
the National League for Nursing (NLN; 2015);
recommendations in the Quality and Safety Education
for Nurses (QSEN) learning modules (2014a); the
Technology Informatics Guiding Education Reform
(TIGER) Initiative (Healthcare Information and
Management Systems Society, 2016); and Nursing
Informatics Deep Dive by the American Association of
Colleges of Nursing (AACN; 2016). These
organizations focus on the need to integrate
informatics competencies into nursing curricula to
prepare future nurses for the tasks of managing data,
information, and knowledge; alleviating errors and
promoting safety; supporting decision making; and
improving the quality of patient care. Nurse educators
are challenged to prepare informatics-competent
nurses who can practice safely in technology-laden
settings.

The TIGER (2007) initiative identified steps toward a
10-year vision and stated a key purpose: “to create a
vision for the future of nursing that bridges the quality
chasm with information technology, enabling nurses to
use informatics in practice and education to provide

safer, higher-quality patient care” (p. 4). The pillars of
the TIGER vision include the following:

Management and Leadership: Revolutionary
leadership that drives, empowers, and executes the
transformation of health care.
Education: Collaborative learning communities that
maximize the possibilities of technology toward
knowledge development and dissemination, driving
rapid deployment and implementation of best
practices.
Communication and Collaboration: Standardized,
person-centered, technology-enabled processes to
facilitate teamwork and relationships across the
continuum of care.
Informatics Design: Evidence-based, interoperable
intelligence systems that support education and
practice to foster quality care and safety.
Information Technology: Smart, people-centered,
affordable technologies that are universal, useable,
useful, and standards based.
Policy: Consistent, incentives-based initiatives
(organizational and governmental) that support
advocacy and coalition-building, achieving and
resourcing an ethical culture of safety.
Culture: A respectful, open system that leverages
technology and informatics across multiple
disciplines in an environment where all
stakeholders trust each other to work together
toward the goal of high quality and safety (p. 4).

The Essentials of Baccalaureate Education for
Professional Nursing Practice (AACN, 2008, pp. 18–
19) includes the following technology-related outcomes
for baccalaureate nursing graduates:

1. Demonstrate skills in using patient care
technologies, information systems, and
communication devices that support safe
nursing practice.

2. Use telecommunication technologies to assist in
effective communication in a variety of
healthcare settings.

3. Apply safeguards and decision-making support
tools embedded in patient care technologies and
information systems to support a safe practice
environment for both patients and healthcare
workers.

4. Understand the use of CIS to document
interventions related to achieving nurse-sensitive
outcomes.

5. Use standardized terminology in a care
environment that reflects nursing’s unique
contribution to patient outcomes.

6. Evaluate data from all relevant sources,
including technology, to inform the delivery of
care.

7. Recognize the role of information technology in
improving patient care outcomes and creating a
safe care environment.

8. Uphold ethical standards related to data security,
regulatory requirements, confidentiality, and
clients’ right to privacy.

9. Apply patient care technologies as appropriate
to address the needs of a diverse patient
population.

10. Advocate for the use of new patient care
technologies for safe, quality care.

11. Recognize that redesign of workflow and care
processes should precede implementation of
care technology to facilitate nursing practice.

12. Participate in the evaluation of information
systems in practice settings through policy and
procedure development.

The report suggests the following sample content for
achieving these student outcomes (AACN, 2008, pp.
19–20):

Use of patient care technologies (e.g., monitors,
pumps, computer-assisted devices)
Use of technology and information systems for
clinical decision making
Computer skills that may include basic software,
spreadsheet, and healthcare databases
Information management for patient safety
Regulatory requirements through electronic data-
monitoring systems
Ethical and legal issues related to the use of
information technology, including copyright, privacy,

and confidentiality issues
Retrieval information systems, including access,
evaluation of data, and application of relevant data
to patient care
Online literature searches
Technological resources for evidence-based
practice
Web-based learning and online literature searches
for self and patient use
Technology and information systems safeguards
(e.g., patient monitoring, equipment, patient
identification systems, drug alerts and IV systems,
and bar coding)
Interstate practice regulations (e.g., licensure,
telehealth)
Technology for virtual care delivery and monitoring
Principles related to nursing workload measurement
and resources and information systems
Information literacy
Electronic health record and physician order entry
Decision support tools
Role of the nurse informaticist in the context of
health informatics and information systems

The Informatics and Healthcare Technologies
Essentials of Master’s Education in Nursing includes
the following elements:

Essential V: Informatics and Healthcare
Technologies

Rationale

Informatics and healthcare technologies
encompass five broad areas:

Use of patient care and other technologies to
deliver and enhance care

Communication technologies to integrate and
coordinate care

Data management to analyze and improve
outcomes of care

Health information management for evidence-
based care and health education

Facilitation and use of electronic health records
to improve patient care (AACN, 2011, pp. 17–
18)

Quality and Safety Education
for Nurses
As nursing science evolves, it is critical that patient
care improves. Sometimes, unfortunately, patient care
is less-than-adequate and is unsafe. Therefore, quality
and safety have become paramount. The QSEN
Institute project seeks to prepare future nurses who will
have the knowledge, skills, and attitudes (KSAs)
necessary to continuously improve the quality and

safety of the healthcare systems within which they
work.

Prelicensure informatics KSAs include the following
(QSEN Institute, 2014c):

INFORMATICS

Knowledge Skills Attitudes

Explain why information

and technology skills are

essential for safe patient

care

Seek

education

about how

information is

managed in

care settings

before

providing care

Apply

technology

and

information

management

tools to

support safe

processes of

care

Appreciate the

necessity for all

health professionals

to seek lifelong,

continuous learning

of information

technology skills

Identify essential

information that must be

available in a common

database to support

patient care

Contrast benefits and

Navigate the

electronic

health record

Document and

plan patient

care in an

Value technologies

that support clinical

decision making,

error prevention, and

care coordination

Protect the

limitations of different

communication

technologies and their

impact on safety and

quality

electronic

health record

Employ

communication

technologies to

coordinate

care for

patients

confidentiality of

protected health

information in

electronic health

records

Describe examples of

how technology and

information management

are related to the quality

and safety of patient care

Recognize the time,

effort, and skill required

for computers,

databases, and other

technologies to become

reliable and effective tools

for patient care

Respond

appropriately

to clinical

decision-

making

supports and

alerts

Use

information

management

tools to

monitor

outcomes of

care

processes

Use high

quality

electronic

sources of

healthcare

information

Value nurses’

involvement in

design, selection,

implementation, and

evaluation of

information

technologies to

support patient care

Definition: Use information and technology to communicate, manage
knowledge, mitigate error, and support decision making.

Reproduced from Cronenwett, L., Sherwood, G., Barnsteiner J.,

Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and

safety education for nurses. Nursing Outlook, 55(3), 122–131.

Copyright 2007, with permission from Elsevier.

Graduate-level informatics KSAs include the following
(QSEN Institute, 2014b):

INFORMATICS

Knowledge Skills Attitudes

Contrast benefits and

limitations of common

information technology

strategies used in the

delivery of patient care

Evaluate the strengths

and weaknesses of

information systems

used in patient care

Participate in the

selection, design,

implementation,

and evaluation of

information

systems

Communicate the

integral role of

information

technology in

nurses’ work

Model behaviors

that support

implementation

and appropriate

use of electronic

health records

Assist team

members to adopt

information

technology by

piloting and

Value the use of

information and

communication

technologies in

patient care

evaluating

proposed

technologies

Formulate essential

information that must

be available in a

common database to

support patient care in

the practice specialty

Evaluate benefits and

limitations of different

communication

technologies and their

impact on safety and

quality

Promote access to

patient care

information for all

professionals who

provide care to

patients

Serve as a

resource for how to

document nursing

care at basic and

advanced levels

Develop

safeguards for

protected health

information

Champion

communication

technologies that

support clinical

decision making,

error prevention,

care coordination,

and protection of

patient privacy

Appreciate the

need for consensus

and collaboration in

developing systems

to manage

information for

patient care

Value the

confidentiality and

security of all

patient records

Describe and critique

taxonomic and

terminology systems

used in national efforts

to enhance

interoperability of

information systems

Access and

evaluate high

quality electronic

sources of

healthcare

information

Participate in the

Value the

importance of

standardized

terminologies in

conducting

searches for patient

information

and knowledge

management systems

design of clinical

decision-making

supports and alerts

Search, retrieve,

and manage data

to make decisions

using information

and knowledge

management

systems

Anticipate

unintended

consequences of

new technology

Appreciate the

contribution of

technological alert

systems

Appreciate the time,

effort, and skill

required for

computers,

databases, and

other technologies

to become reliable

and effective tools

for patient care

Definition: Use information and technology to communicate, manage
knowledge, mitigate error, and support decision making.

Reproduced from Cronenwett, L., Sherwood, G., Pohl, J., Barnsteiner

J., Moore, D., Sullivan, D., . . . Warren, J. (2009). Quality and safety

education for nurses. Nursing Outlook, 57(6), 338–348. Copyright

2009, with permission from Elsevier.

This text is designed to include the necessary content
to prepare nurses for practice in the ever-changing and
technology-laden healthcare environments. Informatics
competence has been recognized as necessary in
order to enhance clinical decision making and improve
patient care for many years. This is evidenced by
Goossen (2000), who reflected on the need for
research in this area and believed that the focus of

nursing informatics research should be on the
structuring and processing of patient information and
the ways that these endeavors inform nursing decision
making in clinical practice. The increased use of
technology to enhance nursing practice, nursing
education, and nursing research will open new
avenues for acquiring, processing, generating, and
disseminating knowledge.

In the future, nursing research will make significant
contributions to the development of nursing science.
Technologies and translational research will abound,
and clinical practices will continue to be evidence
based, thereby improving patient outcomes and
decreasing safety concerns. Schools of nursing will
embrace nursing science as they strive to meet the
needs of changing student populations and the
increasing complexity of healthcare environments.

Summary
Nursing science influences all areas of nursing
practice. This chapter provided an overview of nursing
science and considered how nursing science relates to
typical nursing practice roles, nursing education,
informatics, and nursing research. The Foundation of
Knowledge model was introduced as the organizing
conceptual framework for this text. Finally, the
relationship of nursing science to nursing informatics
was discussed. In subsequent chapters the reader will

learn more about how nursing informatics supports
nurses in their many and varied roles. In an ideal world,
nurses would embrace nursing science as knowledge
users, knowledge managers, knowledge developers,
knowledge engineers, and knowledge workers.

THOUGHT-PROVOKING QUESTIONS

1. Imagine you are in a social situation and
someone asks you, “What does a nurse
do?” Think about how you will capture
and convey the richness that is nursing
science in your answer.

2. Choose a clinical scenario from your
recent experience and analyze it using
the Foundation of Knowledge model. How
did you acquire knowledge? How did you
process knowledge? How did you
generate knowledge? How did you
disseminate knowledge? How did you use
feedback, and what was the effect of the
feedback on the foundation of your
knowledge?

References
American Association of Colleges of

Nursing (AACN). (2008, October 20).
The essentials of baccalaureate

education for professional nursing
practice. Retrieved from
http://www.aacn.nche.edu/education-
resources/BaccEssentials08.pdf

American Association of Colleges of
Nursing (AACN). (2011, March 21).
The essentials of master’s education in
nursing. Retrieved from
http://www.aacn.nche.edu/education-
resources/MastersEssentials11.pdf

American Association of Colleges of
Nursing (AACN). (2016). Background
and overview: Nursing informatics
Deep Dive. Retrieved from
http://www.aacn.nche.edu/qsen-
informatics/background-overview

American Nurses Association. (2016).
What is nursing? Retrieved from
http://www.nursingworld.org/EspeciallyForYou/What-
is-Nursing

Bassendowski, S. (2007). NursingQuest:
Supporting an analysis of nursing
issues. Journal of Nursing Education,

46(2), 92–95. Retrieved from
Education Module database [document
ID: 1210832211].

Cronenwett, L., Sherwood, G., Barnsteiner
J., Disch, J., Johnson, J., Mitchell, P., .
. . Warren, J. (2007). Quality and
safety education for nurses. Nursing
Outlook, 55(3), 122–131.

Girard, N. (2007). Science fiction comes to
the OR. Association of Operating
Room Nurses. AORN Journal, 86(3),
351–353. Retrieved from Health
Module database [document ID:
1333149261].

Goossen, W. (2000). Nursing informatics
research. Nurse Researcher, 8(2), 42.
Retrieved from ProQuest Nursing &
Allied Health Source database
[document ID: 67258628].

Healthcare Information and Management
Systems Society. (2016). The TIGER
initiative. Retrieved from

http://www.himss.org/professional-
development/tiger-initiative

National League for Nursing (NLN).
(2015). A vision for the changing
faculty role: Preparing students for the
technological world of health care.
Retrieved from
https://www.nln.org/docs/default-
source/about/nln-vision-series-
(position-statements)/a-vision-for-
the-changing-faculty-role-preparing-
students-for-the-technological-
world-of-health-care.pdf?sfvrsn=0

Quality and Safety Information for Nurses
(QSEN) Institute. (2014a). Courses:
Learning modules. Retrieved from
http://www.qsen.org/courses/learning-
modules

QSEN Institute. (2014b). Graduate KSAs.
Retrieved from
http://www.qsen.org/competencies/graduate-
ksas

QSEN Institute. (2014c). Pre-licensure
KSAs. Retrieved from
http://www.qsen.org/competencies/pre-
licensure-ksas

Skiba, D. (2007). Faculty 2.0: Flipping the
novice to expert continuum. Nursing
Education Perspectives, 28(6), 342–
344. Retrieved from ProQuest Nursing
& Allied Health Source database
[document ID: 1401240241].

Swan, B., Lang, N., & McGinley, A.
(2004). Access to quality health care:
Links between evidence, nursing
language, and informatics. Nursing
Economic$, 22(6), 325–332. Retrieved
from Health Module database
[document ID: 768191851].

Technology Informatics Guiding Education
Reform. (2007). Evidence and
informatics transforming nursing: 3-
year action steps toward a 10-year
vision. Retrieved from
http://www.aacn.nche.edu/education-
resources/TIGER.pdf

Whitman-Price, R., Kennedy, L., &
Godwin, C. (2012). Use of personal
phones by senior nursing students to
access health care information during
clinical education: Staff nurses’ and
students’ perceptions. Journal of
Nursing Education, 51(11), 642–646.

CHAPTER 2: Introduction
to Information,
Information Science, and
Information Systems

Kathleen Mastrian and Dee McGonigle

Objectives
1. Reflect on the progression from data to

information to knowledge.
2. Describe the term information.
3. Assess how information is acquired.
4. Explore the characteristics of quality

information.
5. Describe an information system.
6. Explore data acquisition or input and

processing or retrieval, analysis, and
synthesis of data.

7. Assess output or reports, documents,
summaries, alerts, and outcomes.

8. Describe information dissemination and
feedback.

9. Define information science.
10. Assess how information is processed.
11. Explore how knowledge is generated in

information science.

Key Terms
» Acquisition

» Alert

» Analysis

» Chief information officers

» Chief technical officers

» Chief technology officers

» Cloud computing

» Cognitive science

» Communication science

» Computer-based information systems

» Computer science

» Consolidated Health Informatics

» Data

» Dissemination

» Document

» Electronic health records

» Federal Health Information Exchange

» Feedback

» Health information exchange

» Health Level Seven

» Indiana Health Information Exchange

» Information

» Information science

» Information systems

» Information technology

» Input

» Interfaces

» Internet2

» Internet of Things (IoT)

» Knowledge

» Knowledge worker

» Library science

» Massachusetts Health Data Consortium

» National Health Information
Infrastructure

» National Health Information Network

» New England Health EDI Network

» Next-Generation Internet

» Outcome

» Output

» Processing

» Rapid Syndromic Validation Project

» Report

» Social sciences

» Stakeholders

» Summaries

» Synthesis

» Telecommunications

Introduction
This chapter explores information, information systems
(ISs), and information science as one of the building
blocks of informatics. (Refer to Figure 2-1.) The key
word here, of course, is information. Information and

information processing are central to the work of health
care. A healthcare professional is known as a
knowledge worker because he or she deals with and
processes information on a daily basis to make it
meaningful and inform his or her practice.

Figure 2-1 Building Blocks of Nursing Informatics

Healthcare information is complex, and many concerns
and issues arise with healthcare information, such as
ownership, access, disclosure, exchange, security,
privacy, disposal, and dissemination. The widespread

implementation of electronic health records (EHRs)
has promoted collaboration among public- and private-
sector stakeholders on a wide-ranging variety of
healthcare information solutions. Some of these
initiatives include Health Level Seven (HL7), the eGov
initiative by Consolidated Health Informatics (CHI),
the National Health Information Infrastructure
(NHII), the National Health Information Network
(NHIN), Next-Generation Internet (NGI), Internet2,
and iHealth record. There are also health information
exchange (HIE) systems, such as Connecting for
Health, the eHealth initiative, the Federal Health
Information Exchange (FHIE), the Indiana Health
Information Exchange (IHIE), the Massachusetts
Health Data Consortium (MHDC), the New England
Health EDI Network (NEHEN), the State of New
Mexico Rapid Syndromic Validation Project (RSVP),
the Southeast Michigan e-Prescribing Initiative, and the
Tennessee Volunteer eHealth Initiative (Goldstein,
Groen, Ponkshe, & Wine, 2007). Many of these were
sparked by the HITECH Act of 2011, which set the
2014 deadline for implementing EHRs and provided
the impetus for HIE initiatives.

It is quite evident from the previous brief listing that
there is a need to remedy healthcare information
technology (IT) concerns, challenges, and issues
faced today. One of the main issues deals with how
healthcare information is managed to make it
meaningful. It is important to understand how people

obtain, manipulate, use, share, and dispose of
information. This chapter deals with the information
piece of this complex puzzle.

Information
Suppose someone states the number 99.5. What does
that mean? It could be a radio station or a score on a
test. Now suppose someone says that Ms. Howsunny’s
temperature is 99.5°F—what does that convey? It is
then known that 99.5 is a person’s temperature. The
data (99.5) were processed to the information that
99.5° is a specific person’s temperature. Data are raw
facts. Information is processed data that has meaning.
Healthcare professionals constantly process data and
information to provide the best possible care for their
patients.

Many types of data exist, such as alphabetic, numeric,
audio, image, and video data. Alphabetic data refer to
letters, numeric data refer to numbers, and
alphanumeric data combine both letters and numbers.
This includes all text and the numeric outputs of digital
monitors. Some of the alphanumeric data encountered
by healthcare professionals are in the form of patients’
names, identification numbers, or medical record
numbers. Audio data refer to sounds, noises, or tones
—for example, monitor alerts or alarms, taped or
recorded messages, and other sounds. Image data
include graphics and pictures, such as graphic monitor

displays or recorded electrocardiograms, radiographs,
magnetic resonance imaging (MRI) outputs, and
computed tomography (CT) scans. Video data refer to
animations, moving pictures, or moving graphics. Using
these data, one may review the ultrasound of a
pregnant patient, examine a patient’s echocardiogram,
watch an animated video for professional development,
or learn how to operate a new technology tool, such as
a pump or monitoring system. The data we gather,
such as heart and lung sounds or X-rays, help us
produce information. For example, if a patient’s X-rays
show a fracture, it is interpreted into information such
as spiral, compound, or hairline. This information is
then processed into knowledge and a treatment plan is
formulated based on the healthcare professional’s
wisdom.

The integrity and quality of the data, rather than the
form, are what matter. Integrity refers to whole,
complete, correct, and consistent data (Figure 2-2).
Data integrity can be compromised through human
error; viruses, worms, or other computer bugs;
hardware failures or crashes; transmission errors; or
hackers entering the system. Figure 2-3 illustrates
some ways that data can be compromised. Information
technologies help to decrease these errors by putting
into place safeguards, such as backing up files on a
routine basis, error detection for transmissions, and
user interfaces that help people enter the data
correctly. High-quality data are relevant and accurately

represent their corresponding concepts. Data are dirty
when a database contains errors, such as duplicate,
incomplete, or outdated records. One author (D.M.)
found 50 cases of tongue cancer in a database she
examined for data quality. When the records were
tracked down and analyzed, and the dirty data were
removed, only one case of tongue cancer remained. In
this situation, the data for the same person had been
entered erroneously 49 times. The major problem was
with the patient’s identification number and name: The
number was changed or his name was misspelled
repeatedly. If researchers had just taken the number of
cases in that defined population as 50, they would
have concluded that tongue cancer was an epidemic,
resulting in flawed information that is not meaningful.
As this example demonstrates, it is imperative that data
be clean if the goal is quality information. The data that
are processed into information must be of high quality
and integrity to create meaning to inform assessments
and decision making.

Figure 2-2 Data Integrity

Figure 2-3 Threats to Data Integrity

To be valuable and meaningful, information must be of
good quality. Its value relates directly to how the
information informs decision making. Characteristics of
valuable, quality information include accessibility,
security, timeliness, accuracy, relevancy,
completeness, flexibility, reliability, objectivity, utility,
transparency, verifiability, and reproducibility.

Accessibility is a must; the right user must be able to
obtain the right information at the right time and in the
right format to meet his or her needs. Getting
meaningful information to the right user at the right time
is as vital as generating the information in the first
place. The right user refers to an authorized user who
has the right to obtain the data and information he or
she is seeking. Security is a major challenge because
unauthorized users must be blocked while the
authorized user is provided with open, easy access
(see the Electronic Security chapter).

Timely information means that the information is
available when it is needed for the right purpose and at
the right time. Knowing who won the lottery last week
does not help one to know if the person won it today.
Accurate information means that there are no errors in
the data and information. Relevant information is a
subjective descriptor, in that the user must have
information that is relevant or applicable to his or her
needs. If a healthcare provider is trying to decide
whether a patient needs insulin and only the patient’s

CT scan information is available, this information is not
relevant for that current need. However, if one needed
information about the CT scan, the information is
relevant.

Complete information contains all of the necessary
essential data. If the healthcare provider needs to
contact the only relative listed for the patient and his or
her contact information is listed but the approval for
that person to be a contact is missing, this information
is considered incomplete. Flexible information means
that the information can be used for a variety of
purposes. Information concerning the inventory of
supplies on a nursing unit, for example, can be used by
nurses who need to know if an item is available for use
for a patient. The nurse manager accesses this
information to help decide which supplies need to be
ordered, to determine which items are used most
frequently, and to do an economic assessment of any
waste.

Reliable information comes from reliable or clean data
gathered from authoritative and credible sources.
Objective information is as close to the truth as one
can get; it is not subjective or biased, but rather is
factual and impartial. If someone states something, it
must be determined whether that person is reliable and
whether what he or she is stating is objective or tainted
by his or her own perspective.

Utility refers to the ability to provide the right
information at the right time to the right person for the
right purpose. Transparency allows users to apply their
intellect to accomplish their tasks while the tools
housing the information disappear into the background.
Verifiable information means that one can check to
verify or prove that the information is correct.
Reproducibility refers to the ability to produce the same
information again.

Information is acquired either by actively looking for it
or by having it conveyed by the environment. All of the
senses (vision, hearing, touch, smell, and taste) are
used to gather input from the surrounding world, and
as technologies mature, more and more input will be
obtained through the senses. Currently, people receive
information from computers (output) through vision,
hearing, or touch (input); and the response (output) to
the computer (input) is the interface with technology.
Gesture recognition is increasing, and interfaces that
incorporate it will change the way people become
informed. Many people access the Internet on a daily
basis seeking information or imparting information.
Individuals are constantly becoming informed,
discovering, or learning; becoming reinformed,
rediscovering, or relearning; and purging what has
been acquired. The information acquired through these
processes is added to the personal knowledge base.
Knowledge is the awareness and understanding of a
set of information and ways that information can be

made useful to support a specific task or arrive at a
decision. This knowledge building is an ongoing
process engaged in while a person is conscious and
going about his or her normal daily activities.

Information Science
Information science has evolved over the last 50 or so
years as a field of scientific inquiry and professional
practice. It can be thought of as the science of
information, studying the application and usage of
information and knowledge in organizations and the
interface or interaction between people, organizations,
and ISs. This extensive, interdisciplinary science
integrates features from cognitive science,
communication science, computer science, library
science, and the social sciences. Information science
is primarily concerned with the input, processing,
output, and feedback of data and information through
technology integration with a focus on comprehending
the perspective of the stakeholders involved and then
applying IT as needed. It is systemically based, dealing
with the big picture rather than individual pieces of
technology.

Information science can also be related to determinism.
Specifically, it is a response to technologic determinism
—the belief that technology develops by its own laws,
that it realizes its own potential, limited only by the
material resources available, and must therefore be

regarded as an autonomous system controlling and
ultimately permeating all other subsystems of society
(Web Dictionary of Cybernetics and Systems, 2007,
para. 1).

This approach sets the tone for the study of information
as it applies to itself, the people, the technology, and
the varied sciences that are contextually related
depending on the needs of the setting or organization;
what is important is the interface between the
stakeholders and their systems, and the ways they
generate, use, and locate information. According to
Cornell University (2010), “Information Science brings
together faculty, students and researchers who share
an interest in combining computer science with the
social sciences of how people and society interact with
information” (para. 1). Information science is an
interdisciplinary, people-oriented field that explores and
enhances the interchange of information to transform
society, communication science, computer science,
cognitive science, library science, and the social
sciences. Society is dominated by the need for
information, and knowledge and information science
focus on systems and individual users by fostering
user-centered approaches that enhance society’s
information capabilities, effectively and efficiently
linking people, information, and technology. This
impacts the configuration and mix of organizations and
influences the nature of work—namely, how knowledge

workers interact with and produce meaningful
information and knowledge.

Information Processing
Information science enables the processing of
information. This processing links people and
technology. Humans are organic ISs, constantly
acquiring, processing, and generating information or
knowledge in their professional and personal lives. This
high degree of knowledge, in fact, characterizes
humans as extremely intelligent organic machines. The
premise of this text revolves around this concept, and
the text is organized on the basis of the Foundation of
Knowledge model: knowledge acquisition, knowledge
processing, knowledge generation, and knowledge
dissemination.

Information is data that are processed using
knowledge. For information to be valuable or
meaningful, it must be accessible, accurate, timely,
complete, cost-effective, flexible, reliable, relevant,
simple, verifiable, and secure. Knowledge is the
awareness and understanding of an information set
and ways that information can be made useful to
support a specific task or arrive at a decision. As an
example, if an architect were going to design a
building, part of the knowledge necessary for
developing a new building is understanding how the
building will be used, what size of building is needed

compared to the available building space, and how
many people will have or need access to this building.
Therefore, the work of choosing or rejecting facts
based on their significance or relevance to a particular
task, such as designing a building, is also based on a
type of knowledge used in the process of converting
data into information. Information can then be
considered data made functional through the
application of knowledge. The knowledge used to
develop and glean knowledge from valuable
information is generative (having the ability to originate
and produce or generate) in nature. Knowledge must
also be viable. Knowledge viability refers to
applications that offer easily accessible, accurate, and
timely information obtained from a variety of resources
and methods and presented in a manner so as to
provide the necessary elements to generate
knowledge.

Information science and computational tools are
extremely important in enabling the processing of data,
information, and knowledge in health care. In this
environment, the hardware, software, networking,
algorithms, and human organic ISs work together to
create meaningful information and generate
knowledge. The links between information processing
and scientific discovery are paramount. However,
without the ability to generate practical results that can
be disseminated, the processing of data, information,
and knowledge is for naught. It is the ability of

machines (inorganic ISs) to support and facilitate the
functioning of people (human organic ISs) that refines,
enhances, and evolves nursing practice by generating
knowledge. This knowledge represents five rights: the
right information, accessible by the right people in the
right settings, applied the right way at the right time.

An important and ongoing process is the struggle to
integrate new knowledge and old knowledge so as to
enhance wisdom. Wisdom is the ability to act
appropriately; it assumes actions directed by one’s own
wisdom. Wisdom uses knowledge and experience to
heighten common sense, and uses insight to exercise
sound judgment in practical matters. It is developed
through knowledge, experience, insight, and reflection.
Wisdom is sometimes thought of as the highest form of
common sense, resulting from accumulated knowledge
or erudition (deep, thorough learning) or enlightenment
(education that results in understanding and the
dissemination of knowledge). It is the ability to apply
valuable and viable knowledge, experience,
understanding, and insight while being prudent and
sensible. Knowledge and wisdom are not synonymous,
because knowledge abounds with others’ thoughts and
information, whereas wisdom is focused on one’s own
mind and the synthesis of one’s own experience,
insight, understanding, and knowledge.

If clinicians are inundated with data without the ability
to process it, the situation results in too much data and

too little wisdom. Consequently, it is crucial that
clinicians have viable ISs at their fingertips to facilitate
the acquisition, sharing, and use of knowledge while
maturing wisdom; this process leads to empowerment.

Information Science and the
Foundation of Knowledge
Information science is a multidisciplinary science that
encompasses aspects of computer science, cognitive
science, social science, communication science, and
library science to deal with obtaining, gathering,
organizing, manipulating, managing, storing, retrieving,
recapturing, disposing of, distributing, and broadcasting
information. Information science studies everything that
deals with information and can be defined as the study
of ISs. This science originated as a subdiscipline of
computer science, as practitioners sought to
understand and rationalize the management of
technology within organizations. It has since matured
into a major field of management and is now an
important area of research in management studies.
Moreover, information science has expanded its scope
to examine the human–computer interaction,
interfacing, and interaction of people, ISs, and
corporations. It is taught at all major universities and
business schools worldwide.

Modern-day organizations have become intensely
aware of the fact that information and knowledge are
potent resources that must be cultivated and honed to
meet their needs. Thus information science or the
study of ISs—that is, the application and usage of
knowledge—focuses on why and how technology can
be put to best use to serve the information flow within
an organization.

Information science impacts information interfaces,
influencing how people interact with information and
subsequently develop and use knowledge. The
information a person acquires is added to his or her
knowledge base. Knowledge is the awareness and
understanding of an information set and ways that
information can be made useful to support a specific
task or arrive at a decision.

Healthcare organizations are affected by and rely on
the evolution of information science to enhance the
recording and processing of routine and intimate
information while facilitating human-to-human and
human-to-systems communications, delivery of
healthcare products, dissemination of information, and
enhancement of the organization’s business
transactions. Unfortunately, the benefits and
enhancements of information science technologies
have also brought to light new risks, such as glitches
and loss of information and hackers who can steal
identities and information. Solid leadership, guidance,

and vision are vital to the maintenance of cost-effective
business performance and cutting-edge, safe
information technologies for the organization. This field
studies all facets of the building and use of information.
The emergence of information science and its impact
on information have also influenced how people
acquire and use knowledge.

Information science has already had a tremendous
impact on society and will undoubtedly expand its
sphere of influence further as it continues to evolve and
innovate human activities at all levels. What visionaries
only dreamed of is now possible and part of reality. The
future has yet to fully unfold in this important arena.

Introduction to Information
Systems
Consider the following scenario: You have just been
hired by a large healthcare facility. You enter the
personnel office and are told that you must learn a new
language to work on the unit where you have been
assigned. This language is used just on this unit. If you
had been assigned to a different unit, you would have
to learn another language that is specific to that unit,
and so on. Because of the differences in various units’
languages, interdepartmental sharing and information
exchange (known as interoperability) are severely
hindered.

This scenario might seem far-fetched, but it is actually
how workers once operated in health care—in silos.
There was a system for the laboratory, one for finance,
one for clinical departments, and so on. As healthcare
organizations have come to appreciate the importance
of communication, tracking, and research, however,
they have developed integrated information systems
that can handle the needs of the entire organization.

Information and IT have become major resources for
all types of organizations, and health care is no
exception (see Box 2-1). Information technologies help
to shape a healthcare organization, in conjunction with
personnel, money, materials, and equipment. Many
healthcare facilities have hired chief information
officers (CIOs) or chief technical officers (CTOs),
also known as chief technology officers. The CIO is
involved with the IT infrastructure, and this role is
sometimes expanded to include the position of chief
knowledge officer. The CTO is focused on
organizationally based scientific and technical issues
and is responsible for technological research and
development as part of the organization’s products and
services. The CTO and CIO must be visionary leaders
for the organization, because so much of the business
of health care relies on solid infrastructures that
generate potent and timely information and knowledge.
The CTO and CIO are sometimes interchangeable
positions, but in some organizations the CTO reports to
the CIO. These positions will become critical roles as

companies continue to shift from being product
oriented to knowledge oriented, and as they begin
emphasizing the production process itself rather than
the product. In health care, ISs must be able to handle
the volume of data and information necessary to
generate the needed information and knowledge for
best practices, because the goal is to provide the
highest quality of patient care.

BOX 2-1 EXAMPLES OF INFORMATION

SYSTEMS

Information
System

How It Is Used

Clinical

Information

System

(CIS)

Comprehensive and integrative system that

manages the administrative, financial, and

clinical aspects of a clinical facility; a CIS

should help to link financial and clinical

outcomes. An example is the EHR.

Decision

Support

System

(DSS)

Organizes and analyzes information to help

decision makers formulate decisions when

they are unsure of their decision’s possible

outcomes. After gathering relevant and

useful information, develops “what if”

models to analyze the options or choices

and alternatives.

Executive

Support

System

Collects, organizes, analyzes, and

summarizes vital information to help

executives or senior management with

strategic decision making. Provides a quick

view of all strategic business activities.

Geographic

Information

System

(GIS)

Collects, manipulates, analyzes, and

generates information related to geographic

locations or the surface of the earth;

provides output in the form of virtual models,

maps, or lists.

Management

Information

Systems

(MIS)

Provides summaries of internal sources of

information, such as information from the

transaction processing system, and

develops a series of routine reports for

decision making.

Office

Systems

Facilitates communication and enhances

the productivity of users needing to process

data and information.

Transaction

Processing

System

(TPS)

Processes and records routine business

transactions, such as billing systems that

create and send invoices to customers, and

payroll systems that generate employees’

pay stubs and wage checks and calculate

tax payments.

Hospital

Information

System

(HIS)

Manages the administrative, financial, and

clinical aspects of a hospital enterprise. It

should help to link financial and clinical

outcomes.

Information Systems

ISs can be manually based, but for the purposes of this
text, the term refers to computer-based information
systems (CBISs). According to Jessup and Valacich
(2008), CBISs “are combinations of hardware, software
and telecommunications networks that people build
and use to collect, create, and distribute useful data,
typically in organizational settings” (p. 10). Along the
same lines, ISs are also defined as “a collection of
interconnected elements that gather, process, store
and distribute data and information while providing a
feedback structure to meet an objective” (Stair &
Reynolds, 2016, p. 4). ISs are designed for specific
purposes within organizations. They are only as
functional as the decision-making capabilities, problem-
solving skills, and programming potency built in and the
quality of the data and information input into them. The
capability of the IS to disseminate, provide feedback,
and adjust the data and information based on these
dynamic processes is what sets them apart. The IS
should be a user-friendly entity that provides the right
information at the right time and in the right place.

An IS acquires data or inputs; processes data through
the retrieval, analysis, or synthesis of those data;
disseminates or outputs information in the form of
reports, documents, summaries, alerts, prompts, or
outcomes; and provides for responses or feedback.
Input or data acquisition is the activity of collecting and
acquiring raw data. Input devices include combinations
of hardware, software, and telecommunications,

including keyboards, light pens, touch screens, mice or
other pointing devices, automatic scanners, and
machines that can read magnetic ink characters or
lettering. To watch a pay-per-view movie, for example,
the viewer must first input the chosen movie, verify the
purchase, and have a payment method approved by
the vendor. The IS must acquire this information before
the viewer can receive the movie.

Processing—the retrieval, analysis, or synthesis of
data—refers to the alteration and transformation of the
data into helpful or useful information and outputs. The
processing of data can range from storing it for future
use; to comparing the data, making calculations, or
applying formulas; to taking selective actions.
Processing devices consist of combinations of
hardware, software, and telecommunications and
include processing chips where the central processing
unit (CPU) and main memory are housed. Some of
these chips are quite ingenious. According to Schupak
(2005), the bunny chip could save the pharmaceutical
industry money while sparing “millions of furry
creatures, with a chip that mimics a living organism”
(para. 1). The HµREL Corporation has developed
environments or biologic ISs that reside on chips and
actually mimic the functioning of the human body.
Researchers can use these environments to test for
both the harmful and beneficial effects of drugs,
including those that are considered experimental and
that could be harmful if used in human and animal

testing. Such chips also allow researchers to monitor a
drug’s toxicity in the liver and other organs.

One patented HµREL microfluidic “biochip” comprises
an arrangement of separate but fluidically
interconnected “organ” or “tissue” compartments. Each
compartment contains a culture of living cells drawn
from, or engineered to mimic the primary functions of,
the respective organ or tissue of a living animal.
Microfluidic channels permit a culture medium that
serves as a “blood surrogate” to recirculate just as in a
living system, driven by a microfluidic pump. The
geometry and fluidics of the device are fashioned to
simulate the values of certain related physiologic
parameters found in the living creature. Drug
candidates or other substrates of interest are added to
the culture medium and allowed to recirculate through
the device. The effects of drug compounds and their
metabolites on the cells within each respective organ
compartment are then detected by measuring or
monitoring key physiologic events. The cell types used
may be derived from either standard cell culture lines
or primary tissues (HµREL Corporation, 2010, para.
2–3). As new technologies such as the HµREL chips
continue to evolve, more and more robust ISs that can
handle a variety of biological and clinical applications
will be seen.

Returning to the movie rental example, the IS must
verify the data entered by the viewer and then process

the request by following the steps necessary to provide
access to the movie that was ordered. This processing
must be instantaneous in today’s world, where
everyone wants everything now. After the data are
processed, they are stored. In this case, the rental
must also be processed so the vendor receives
payment for the movie, whether electronically, via a
credit card or checking account withdrawal, or by
generating a bill for payment.

Output or dissemination produces helpful or useful
information that can be in the form of reports,
documents, summaries, alerts, or outcomes. A report
is designed to inform and is generally tailored to the
context of a given situation or user or user group.
Reports may include charts, figures, tables, graphics,
pictures, hyperlinks, references, or other
documentation necessary to meet the needs of the
user. A documentrepresents information that can be
printed, saved, emailed, or otherwise shared, or
displayed. Summaries are condensed versions of the
original information designed to highlight the major
points. An alert is comprised of warnings, feedback, or
additional information necessary to assist the user in
interacting with the system. An outcome is the
expected result of input and processing. Output
devices are combinations of hardware, software, and
telecommunications and include sound and speech
synthesis outputs, printers, and monitors.

Continuing with the movie rental example, the IS must
be able to provide the consumer with the movie
ordered when it is wanted and somehow notify the
purchaser that he or she has, indeed, purchased the
movie and is granted access. The IS must also be able
to generate payment either electronically or by
generating a bill, while storing the transactional record
for future use.

Feedback or responses are reactions to the inputting,
processing, and outputs. In ISs, feedback refers to
information from the system that is used to make
modifications in the input, processing actions, or
outputs. In the movie rental example, what if the
consumer accidentally entered the same movie order
three times, but really wanted to order the movie only
once? The IS would determine that more than one
movie order is out of range for the same movie order at
the same time and provide feedback. Such feedback is
used to verify and correct the input. If undetected, the
viewer’s error would result in an erroneous bill and
decreased customer satisfaction while creating more
work for the vendor, which would have to engage in
additional transactions with the customer to resolve this
problem. The Nursing Informatics Practice
Applications: Care Delivery section of this text provides
detailed descriptions of clinical ISs that operate on
these same principles to support healthcare delivery.

Summary
Information systems deal with the development, use,
and management of an organization’s IT infrastructure.
An IS acquires data or inputs; processes data through
the retrieval, analysis, or synthesis of those data;
disseminates or outputs in the form of reports,
documents, summaries, alerts, or outcomes; and
provides for responses or feedback. Quality decision-
making and problem-solving skills are vital to the
development of effective, valuable ISs. Today’s
organizations now recognize that their most precious
asset is their information, as represented by their
employees, experience, competence or know-how, and
innovative or novel approaches, all of which are
dependent on a robust information network that
encompasses the information technology
infrastructure.

In an ideal world, all ISs would be fluid in their ability to
adapt to any and all users’ needs. They would be
Internet oriented and global, where resources are
available to everyone. Think of cloud computing—it is
just the beginning point from which ISs will expand and
grow in their ability to provide meaningful information to
their users. As technologies advance, so will the skills
and capabilities to comprehend and realize what ISs
can become. As wearable tracking technologies and
other health-related mobile applications expand, more
robust and timely health data will be generated, and

this data will need to be processed into meaningful
information. “Practitioners and medical researchers can
look forward to technologies that enable them to apply
data analysis to develop new insights into finding cures
for difficult diseases. Healthcare CIOs and other IT
leaders can expect to be called upon to manage all the
new data and devices that will be transforming
healthcare as we know it” (Schindler, 2015, para. 2).
Devices with sensors communicating with each other is
known as the Internet of Things (IoT) and the future
possibilities for health care are tremendous. “The IoT
raises the bar—enabling connection and
communication from anywhere to anywhere—and
allows analytics to replace the human decision-maker”
(Glasser, 2015, para. 3). Essentially, the sensor-
collected data are transmitted to another technology,
triggering an action or an alert that prompts feedback
for an action. For example, “imagine a miniaturized,
implanted device or skin patch that monitors a
diabetic’s blood sugar, movement, skin temperature
and more, and informs an insulin pump to adjust the
dosage” (para. 8).

It is important to continue to develop and refine
functional, robust, visionary ISs that meet the current
meaningful information needs while evolving systems
that are even better prepared to handle future
information and knowledge needs of the healthcare
industry.

THOUGHT-PROVOKING QUESTIONS

1. How do you acquire information? Choose
2 hours out of your busy day and try to
notice all of the information that you
receive from your environment. Keep
diaries indicating where the information
came from and how you knew it was
information and not data.

2. Reflect on an IS with which you are
familiar, such as the automatic banking
machine. How does this IS function?
What are the advantages of using this
system (i.e., why not use a bank teller
instead)? What are the disadvantages?
Are there enhancements that you would
add to this system?

3. In health care, think about a typical day of
practice and describe the setting. How
many times does the nurse interact with
ISs? What are the ISs that we interact
with, and how do we access them? Are
they at the bedside, handheld, or station
based? How do their location and ease of
access impact nursing care?

4. Briefly describe an organization and
discuss how our need for information and
knowledge impacts the configuration and
interaction of that organization with other
organizations. Also discuss how the need

for information and knowledge influences
the nature of work or how knowledge
workers interact with and produce
information and knowledge in this
organization.

5. If you could meet only four of the rights
discussed in this chapter, which one
would you omit and why? Also, provide
your rationale for each right you chose to
meet.

References
Cornell University. (2010). Information

science. Retrieved from
http://www.infosci.cornell.edu

Goldstein, D., Groen, P., Ponkshe, S., &
Wine, M. (2007). Medical informatics
20/20. Sudbury, MA: Jones and
Bartlett.

Glasser, J. (2015). How the Internet of
Things will affect health care. Hospitals
and Health Networks. Retrieved from
http://www.hhnmag.com/articles/3438-

how-the-internet-of-things-will-
affect-health-care

HµREL Corporation. (2010). Human-
relevant: HµREL. Technology
overview. Retrieved from
http://www.hurelcorp.com/overview.php

Jessup, L., & Valacich, J. (2008).
Information systems today (3rd ed.).
Upper Saddle River, NJ: Pearson
Prentice Hall.

Schindler, E. (2015). Healthcare IT: Hot
Trends for 2016, Part 1.
InformationWeek. Retrieved from
http://www.informationweek.com/healthcare/leadership/healthcare-
it-hot-trends-for-2016-part-1/d/d-
id/1323722

Schupak, A. (2005). Technology: The
bunny chip. Forbes. Retrieved from
http://www.forbes.com/forbes/2005/0815/053.html

Stair, R., & Reynolds, G. (2016).
Principles of information systems (12th

ed.). Boston, MA: Cengage Learning.

Web Dictionary of Cybernetics and
Systems. (2007). Technological
determinism. Retrieved from
http://pespmc1.vub.ac.be/ASC/TECHNO_DETER.html

CHAPTER 3: Computer
Science and the
Foundation of
Knowledge Model

Dee McGonigle, Kathleen Mastrian, and June Kaminski

Objectives
1. Describe the essential components of

computer systems, including both
hardware and software.

2. Recognize the rapid evolution of
computer systems and the benefit of
keeping up-to-date with current trends
and developments.

3. Analyze how computer systems function
as tools for managing information and
generating knowledge.

4. Define the concept of human–technology
interfaces.

5. Assess how computers can support
collaboration, networking, and
information exchange.

Key Terms
» Acquisition

» AMOLED (Active Matrix Organic Light-
Emitting Diode)

» Applications

» Arithmetic logic units

» Basic input/output system (BIOS)

» Binary system

» Bit

» Bus

» Byte

» Cache memory

» Central processing unit (CPU)

» Cloud computing

» Cloud storage

» Communication software

» Compact disc read-only memory (CD-
ROM)

» Compact disc-recordable (CD-R)

» Compact disc-rewritable (CD-RW)

» Compatibility

» Computer

» Computer science

» Conferencing software

» Creativity software

» Database

» Desktop

» Digital video disc (DVD)

» Digital video disc-recordable (DVD-R)

» Digital video disc-rewritable (DVD-RW)

» Dissemination

» Dots per inch (DPI) switch

» Double data rate synchronous dynamic
random-access memory (DDR SDRAM)

» Dynamic random access memory
(DRAM)

» Email

» Email client

» Electronically erasable programmable
read-only memory (EEPROM)

» Embedded device

» Exabyte (EB)

» Executes

» Extensibility

» FireWire

» Firmware

» Flash memory

» Gigabyte (GB)

» Gigahertz

» Graphical user interface

» Graphics card

» Haptic

» Hard disk

» Hard drive

» Hardware

» High-definition multimedia interface
(HDMI)

» Information

» Information Age

» Infrastructure as a service (IaaS)

» Instant message (IM)

» Integrated drive electronics (IDE)

» Internet browser

» IPS LCD (In-Plane Switching Liquid
Crystal Display)

» Keyboard

» Knowledge

» Laptop

» Main memory

» Mainframes

» Megabyte (MB)

» Megahertz

» Memory

» Microprocessor

» Microsoft Surface

» Millions of instructions per second
(MIPS)

» Mobile device

» Modem

» Monitor

» Motherboard

» Mouse

» MPEG-1 Audio Layer-3 (MP3)

» Networks

» Office suite

» Open source

» Operating system (OS)

» Parallel port

» Peripheral component interconnection
(PCI)

» Personal computer (PC)

» Petabytes (PB)

» Platform as a service (PaaS)

» Plug and play

» Port

» Portability

» Portable operating system interface for
UNIX (POSIX)

» Power supply

» Presentation

» Private cloud

» Processing

» Processor

» Productivity software

» Professional development

» Programmable read-only memory
(PROM)

» Public cloud

» Publishing

» Quantum bits (Qubits)

» Quantum computing

» QWERTY

» Random-access memory (RAM)

» Read-only memory (ROM)

» Security

» Serial port

» Small Computer System Interface
(SCSI)

» Software

» Software as a service (SaaS)

» Sound card

» Spreadsheet

» Supercomputers

» Synchronous dynamic random-access
memory (SDRAM)

» Technology

» Terabytes (TB)

» Throughput

» Touch pad

» Touch screen

» Universal serial bus (USB)

» USB flash drive

» User friendly

» User interface

» Video adapter card

» Virtual memory

» Wearable technology

» Wi-Fi

» Wisdom

» Word processing

» World Wide Web (WWW)

» Yottabyte (YB)

» Zettabyte (ZB)

Introduction
In this chapter, the discipline of computer science is
introduced through a focus on computers and the
hardware and software that make up these evolving
systems; computer science is one of the building
blocks of nursing informatics (refer to Figure 3-1).
Computer science offers extremely valuable tools
that, if used skillfully, can facilitate the acquisition and
manipulation of data and information by nurses, who
can then synthesize these into an evolving knowledge
and wisdom base. This process can facilitate
professional development and the ability to apply
evidence-based practice decisions within nursing care,
and if the results are disseminated and shared, can
also advance the professional knowledge base.

Figure 3-1 Building Blocks of Nursing Informatics

This chapter begins with a look at common computer
hardware, followed by a brief overview of operating,
productivity, creativity, and communication software. It
concludes with a glimpse at how computer systems
help to shape knowledge and collaboration and an
introduction to human–technology interface dynamics.

The Computer as a Tool for
Managing Information and

Generating Knowledge
Throughout history, various milestones have signaled
discoveries, inventions, or philosophic shifts that
spurred a surge in knowledge and understanding
within the human race. The advent of the computer is
one such milestone, which has sparked an intellectual
metamorphosis whose boundaries have yet to be fully
understood. Computer technology has ushered in
what has been called the Information Age, an age
when data, information, and knowledge are both
accessible and able to be manipulated by more people
than ever before in history. How can a mere machine
lead to such a revolutionary state of knowledge
potential? To begin to answer this question, it is best to
examine the basic structure and components of
computer systems.

Essentially, a computer is an electronic information-
processing machine that serves as a tool with which to
manipulate data and information. The easiest way to
begin to understand computers is to realize they are
input–output systems. These unique machines accept
data input via a variety of devices, process data
through logical and arithmetic rendering, store the data
in memory components, and output data and
information to the user.

Since the advent of the first electronic computer in the
mid-1940s, computers have evolved to become

essential tools in every walk of life, including the
profession of nursing. The complexity of computers has
increased dramatically over the years, and will continue
to do so. “Computing has changed the world more than
any other invention of the past hundred years, and has
come to pervade nearly all human endeavors. Yet, we
are just at the beginning of the computing revolution;
today’s computing offers just a glimpse of the potential
impact of computers” (Evans, 2010, p. 3). Major
computer manufacturers and researchers, such as
Intel, have identified the need to design computers to
mask this growing complexity. The sophistication of
computers is evolving at amazing speed, yet ease of
use or user-friendly aspects are also increasing
accordingly. This is achieved by honing hardware and
software capabilities until they work seamlessly
together to ensure user-friendly, intuitive tools for users
of all levels of expertise. Box 3-1 provides information
about haptic technology, computing surfaces, and
multi-touch interfaces, which are evolving technologies.

BOX 3-1 IMMERSION, MICROSOFT,

AND PQ LABS INTERFACES

Dee McGonigle

Do not get too attached to your mouse and
keyboard, because they will be outdated soon if
Immersion, Microsoft, and PQ Labs have their
way. From Immersion’s (2016) haptic

technology, the Microsoft Surface (Microsoft
Corporation, 2016), and PQ Labs (2016) multi-
touch capabilities, have you ever thought of
digital information you can touch and grab? The
sense of touch is a powerful sense that we use
daily. Haptic technology continues to advance
and “brings the sense of touch to digital content”
(Immersion, 2016, para. 4). Haptic technology
combined with a visual display can be used to
prepare users for tasks necessitating hand–eye
coordination, such as surgical procedures.
Microsoft and PQ Labs are leading us into and
evolving the next generation of computing,
known as surface or table computing. Surface or
table computing consists of a multi-touch,
multiuser interface that allows one to “grab”
digital information and then collaborate, share,
and store that information, without using a
mouse or keyboard—just the hands and fingers
and devices such as a digital camera or
smartphone. These interfaces can actually
sense objects, touch, and gestures from many
users.

We can enter a restaurant and interact with the
menu through the surface of the table where you
sit to eat. Once you have completed your order,
you can begin computing by using the
capabilities built into the surface or using your
own device, such as a smartphone. You can set

a smartphone on the table’s surface and
download images, graphics, and text to the
surface. You can even communicate with others
using full audio and video while waiting for your
order. When you have finished eating, you
simply set your credit card on the surface and it
is automatically charged; you pick up your credit
card and leave. This is a different kind of eating
experience—but one that will become
commonplace for the next generation of users.
You can routinely experience this in Las Vegas,
as well as in selected casinos, banks,
restaurants, and hotels throughout the world.

You should seek to explore this new interface,
which will forever change how we interact and
compute. Think of the ramifications for health
care especially as it relates to the haptic
experience and wearables. Explore the
Immersion reference provided for you.

REFERENCES

Immersion. (2016). Touch. Feel.
Engage. Retrieved from
http://www.immersion.com/wearables

Microsoft Corporation. (2016).
Designed on Surface: A global
art project. Retrieved from

https://www.microsoft.com/surface/en-
us/art

PQ Labs. (2016). Introducing G5: 4K
Touch Fidelity. Retrieved from
http://multitouch.com/product.html

As our capabilities evolve, so does the complexity of
computer operations. The goal for vendors that provide
computer systems and software is to decrease the
learning curve for the user while enhancing the user’s
capacity to manipulate the system to meet their
computing needs. Therefore, the complexity of the
operation is concealed by the ease of use.

One example of this type of complexity masked in
simplicity is the evolution of “plug and play” computer
add-ons, where a peripheral, such as an iPod or game
console, can be simply plugged into a serial or other
port and instantly used.

Computers are universal machines, because they are
general-purpose, symbol-manipulating devices that can
perform any task represented in specific programs. For
instance, they can be used to draw an image, calculate
statistics, write an essay, or record nursing care data.

In a nutshell, computers can be used for data and
information storage, retrieval, analysis, generation, and
transformation.

Most computers are based on scientist John Von
Neumann’s model of a processor–memory–input–
output architecture. In this model, the logic unit and
control unit are parts of the processor, the memory is
the storage region, and the input and output segments
are provided by the various computer devices, such as
the keyboard, mouse, monitor, and printer. Recent
developments have provided alternative configurations
to the Von Neumann model—for example, the parallel
computing model, where multiple processors are set up
to work together. Nevertheless, today’s computer
systems share the same basic configurations and
components inherent in the earliest computers.

Components

Hardware
Computer hardware refers to the actual physical body
of the computer and its components. Several key
components in the average computer work together to
shape a complex yet highly usable machine that serves
as a tool for knowledge management, communication,
and creativity.

Protection: The Casing

The most noticeable component of any computer is the
outer case. Desktop personal computers have either a
desktop case, which lies horizontally (flat) on a desk,
often with the computer monitor positioned on top of it;
or a tower case, which stands vertically, and usually
sits beside the monitor or on a lower shelf or the floor.
Most cases come equipped with a case fan, which is
extremely critical for keeping the computer components
cool when in use. Laptop and surface computers
combine the components into a flat rectangular casing
that is attached to the hinged or foldable monitor.
Smartphones also have a protective outer plastic or
metal case with a display screen.

Central Processing Unit (CPU)/Processor

The central processing unit (CPU) is an older term
for the processor and microprocessor. Sometimes
conceptualized as the “brain” of the computer, the
processor is the computer component that actually
executes, calculates, and processes the binary
computer code (which consists of various
configurations of 0s and 1s), instigated by the
operating system (OS) and other applications on the
computer. The processor and microprocessor serve as
the command center that directs the actions of all other
computer components, and they manage both
incoming and outgoing data that are processed across
components. Some of the best processors include the

AMD FX-9590, AMD FX-8320, AMD FX-6300, Intel
Core i7-5820K, Intel Core i7- 4930K, Intel Core i7-
5960X, Intel Core i5-6600K, and Intel Xeon processor
(Futuremark, 2016).

The processor contains specific mechanical units,
including registers, arithmetic logic units, a floating
point unit, control circuitry, and cache memory.
Together, these inner components form the computer’s
central processor. Registers consist of data-storing
circuits whose contents are processed by the adjacent
arithmetic and logic units or the floating point unit.
Cache memory is extremely quick memory that holds
whatever data and code are being used at any one
time. The processor uses the cache to store in-process
data so that it can be quickly retrieved as needed. The
processor is protected by a heat sink, a copper or
aluminum metal block that cools the processor (often
with the help of a fan) to prevent overheating (refer to
Figure 3-2).

Figure 3-2 Computer Components

Keyboard © Undrey/Shutterstock; mouse © Pressmaster/Shutterstock;

microphone © VectorShow/Shutterstock; touch pad ©

donfiore/Shutterstock; pen drawing a diagram © Syda

Productions/Shutterstock; USB drive © DecemberDah/Shutterstock; CPU

© Péter Gudella/Dreamstime.com; RAM © NorGal/Shutterstock; hard

drive © mike mols/Shutterstock; monitor © Leone_V/Shutterstock; printer

© Billion Photos/Shutterstock; speakers © Krailurk Warasup/Shutterstock;

TV © JTal/Shutterstock; flash drive © Ksander/Shutterstock

In the past, the speed and power of a processor were
measured in units of megahertz and was written as a

value in MHz (e.g., 400 MHz, meaning the
microprocessor ran at 400 MHz, executing 400 million
cycles per second). Today, it is more common to see
the speed measured in gigahertz (1 GHz is equal to
1,000 MHz); thus a processor that operates at 4 GHz is
1,000 times faster than an older one that operated at 4
MHz. The more cycles a processor can complete per
second, the faster computer programs can run.
However, according to Anderson (2016),

Intel has said that new technologies in
chip manufacturing will favour better
energy consumption over faster
execution times—effectively calling an
end to “Moore’s Law,” which successfully
predicted the doubling of density in
integrated circuits, and therefore speed,
every two years. (para. 1)

For example, the Intel Xeon processor E5-2699 v4 has
a speed of 2.20 Ghz with 55 MB cache (Intel
Corporation, 2016), making it more efficient at a lower
speed.

In recent years, processor manufacturers, such as
Intel, have moved to multicore microprocessors, which
are chips that combine two or more processors. In fact,
multiple microprocessors have become a standard in
both personal and professional-level computers.

Minicomputers were replaced by servers using
microprocessors and multiprocessors have replaced
most mainframes.

As mobile devices and embedded devices are being
integrated into our daily routines, mainframes can
create secure transactions with the analytics necessary
for organizations to improve their business processes.
IBM has found its niche and continues to build
mainframes. According to Alba (2015),

The concept of a “mobile transaction” is a
bit of marketing-speak. Tons of
transactions take place via mobile
devices, and the mainframe is good at
transaction processing. Put them
together, and voilà: a computer the size
of a backyard shed becomes a mobile
product. (para. 6)

Powerful supercomputers are also using collections
of microprocessors.

Motherboard

The motherboard has been called the “central
nervous system” of the computer because it facilitates
communication among all of the different computer
components. This makes it a key foundational
component because all other components are

connected to it in some way (either directly via local
sockets, attached directly to it, or connected via
cables). This includes universal serial bus (USB)
controllers, Ethernet network controllers, integrated
graphics controllers, and so forth. The essential
structures of the motherboard include the major
chipset, Super Input/Output chip, basic input/output
system read-only memory, bus communications
pathways, and a variety of sockets that allow
components to plug into the board. The chipset (often a
pair of chips) determines the computer’s CPU type and
memory. It also houses the north bridge and south
bridge controllers that allow the buses to transfer data
from one to another.

Power Supply

The power supply is a critical component of any
computer, because it provides the essential electrical
energy needed to allow a computer to operate. The
power supply unit converts the 120-volt AC main power
(provided via the power cable from the wall socket into
which the computer is plugged) into low-voltage DC
power. Computers depend on a reliable, steady supply
of DC power to function properly. The more devices
and programs used on a computer, the larger the
power supply should be to avoid damage and
malfunctioning. Power supplies normally range from
160 to 700 watts, with an average of 300 to 400 watts.
Most contemporary power supply units come equipped

with at least one fan to cool the unit under heavy use.
The power supply is controlled by pressing the on and
off switch, as well as the reset switch (which restarts
the system) of a computer.

Laptop and other portable computing machines, such
as electronic readers and tablet computers, are
equipped with a both rechargeable battery power
supply and the standard plug-in variety.

Hard Disk

This component is so named because of the rigid hard
disks that reside in it, which are mounted to a spindle
that is spun by a motor when in use. Drive heads (most
computers have two or more heads) produce a
magnetic field through their transducers that
magnetizes the disk surface as a voltage is applied to
the disk. The hard disk acts as a permanent data
storage area that holds gigabytes (GB) or even
terabytes (TB) worth of data, information, documents,
and programs saved on the computer, even when the
computer is shut off. Disk drives are not infallible,
however, so backing up important data is imperative.

The computer writes binary data to the hard drive by
magnetizing small areas of its surface. Each drive head
is connected to an actuator that moves along the disk
to hover over any point on the disk surface as it spins.
The parts of the hard disk are encased in a sealed unit.

The hard drive is managed by a disk controller, which
is a circuit board that controls the motor and actuator
arm assembly. The hard drive produces the voltage
waveform that contacts the heads to write and read
data, and handles communications with the
motherboard. It is usually located within the computer’s
hard outer casing. Some people also attach a second
hard drive externally, to increase available memory or
to back up data.

Main Memory or Random-Access Memory

Random-access memory (RAM) is considered to be
volatile memory because it is a temporary storage
system that allows the processor to access program
codes and data while working on a task. The contents
of RAM are lost once the system is rebooted, is shut
off, or loses power.

The memory is actually situated on small chip boards,
which sport rows of pins along the bottom edge and
are plugged into the motherboard of the computer.
These memory chips contain complex arrays of tiny
memory circuits that can be either set by the processor
during write operations (puts them into storage) or read
during data retrieval. The circuits store the data in
binary form as either a low (on) voltage stage,
expressed as a 0, or a high (off) voltage stage,
expressed as a 1. All of the work being done on a
computer resides in RAM until it is saved onto the hard

drive or other storage drive. Computers generally come
with 2 GB of RAM or more, and some offer more RAM
via graphics cards and other expansion cards.

A certain portion of the RAM, called the main memory,
serves the hard disk and facilitates interactions
between the hard disk and central processor. Main
memory is provided by dynamic random access
memory (DRAM) and is attached to the processor
using specific addresses and data buses.

Synchronous dynamic random-access memory
(SDRAM) (also known as static dynamic RAM)
protects its data bits. The newer chip is double data
rate synchronous dynamic random-access memory
(DDR SDRAM) that allows for greater bandwidth and
twice the transfers per the computer’s internal clock’s
unit of time.

Read-Only Memory

Read-only memory (ROM) is essential permanent or
semipermanent nonvolatile memory that stores saved
data and is critical in the working of the computer’s OS
and other activities. ROM is stored primarily in the
motherboard, but it may also be available through the
graphics card, other expansion cards, and peripherals.
In recent years, rewritable ROM chips that may include
other forms of ROM, such as programmable read-
only memory (PROM), erasable ROM, electronically

erasable programmable read-only memory
(EEPROM), and flash memory (a variation of
electronically erasable programmable ROM), have
become available.

Basic Input/Output System

The basic input/output system (BIOS) is a specific
type of ROM used by the computer when it first boots
up to establish basic communication between the
processor, motherboard, and other components. Often
called boot firmware, it controls the computer from the
time the machine is switched on until the primary OS
(e.g., Windows, Mac OS X, or Linux) takes over. The
firmware initializes the hardware and boots (loads and
executes) the primary OS.

Virtual Memory

Virtual memory is a special type of memory that is
stored on the hard disk to provide temporary data
storage so data can be swapped in and out of the RAM
as needed. This capability is particularly handy when
working with large data-intensive programs, such as
games and multimedia.

Integrated Drive Electronics Controller

The integrated drive electronics (IDE) controller
component is the primary interface for the hard drive,
compact disk read-only memory (CD-ROM), digital

video disk (DVD) drive, and the floppy disk drive
(found largely on pre-2010 computers).

Peripheral Component Interconnection Bus

This component is important for connecting additional
plug-in components to the computer. It uses a series of
slots on the motherboard to allow peripheral
component interconnection (PCI) card plug-in.

Small Computer System Interface

The Small Computer System Interface (SCSI)
component provides the means to attach additional
devices, such as scanners and extra hard drives, to the
computer.

DVD/CD Drive

The CD-ROM drive reads and records data to portable
CDs, using a laser diode to emit an infrared light beam
that reflects onto a track on the CD using a mirror
positioned by a motor. The light reflected on the disk is
directed by a system of lenses to a photodetector that
converts the light pulses into an electrical signal; this
signal is then decoded by the drive electronics to the
motherboard. There are compact disk-recordable
(CD-R) and compact disk-rewritable (CD-RW),
digital video disk-recordable (DVD-R), and digital
video disk-rewritable (DVD-RW) drives. A DVD drive
can do everything a CD drive can do, plus it can play

the content of disks and, if it is a recordable unit, can
record data on blank DVDs.

Flash or USB Flash Drive

This portable memory device uses electronically
erasable programmable ROM to provide fast
permanent memory. The USB flash drive is typically a
removable and rewritable device that includes flash
memory and an integrated USB interface. They are
easily portable due to their small size and are durable
and dependable, and obtain their power from the
device they are connected to via the USB port.

Modem

A modem is a component that can be situated either
externally (external modem) or internally (internal
modem) relative to the computer and enables Internet
connectivity via a cable connection through network
adapters situated within the computer apparatus.

Connection Ports

All computers have connection ports made to fit
different types of plug-in devices. These ports include a
monitor cable port, keyboard and mouse ports, a
network cable port, microphone/speaker/auxiliary input
ports, USB ports, and printer ports (SCSI or parallel).
These ports allow data to move to and from the

computer via peripheral or storage devices. Specific
ports include the following:

Parallel port: Connects to a printer
Serial port: Connects to an external modem
USB: Connects to a myriad of plug-in devices, such
as portable flash drives, digital cameras, MPEG-1
Audio Layer-3 (MP3) players, graphics tablets, and
light pens, using a plug-and-play connection (the
ability to add devices automatically). The
development of the USB Type-C–to–high
definition multimedia interface (HDMI) adapter
(Sexton, 2016) has expanded connectivity and
transfer. HDMI is replacing analog video standards
as an audio/video interface that can transfer
compressed and uncompressed video and digital
audio data from any device that is HDMI-compliant
to compatible monitors, televisions, video
projectors, and audio devices.
FireWire (IEEE 1394): Often used to connect
digital-video devices to the computer
Ethernet: Connects networking apparatus, such as
Internet and modem cables

Graphics Card

Most computers come equipped with a graphics
accelerator card slotted in the microprocessor of a
computer to process image data and output those data
to the monitor. These in situ graphic cards provide

satisfactory graphics quality for two-dimensional art
and general text and numerical data. However, if a user
intends to create or view three-dimensional images or
is an active game user, one or more graphics
enhancement cards are often installed.

Video Adapter Cards

Video adapter cards provide video memory, a video
processor, and a digital-to-analog converter that works
with the processor to output higher quality video
images to the monitor.

Sound Card

The sound card converts digital data into an analog
signal that is then output to the computer’s speakers or
headphones. The reverse is also accomplished by
inputting a signal from a microphone or other audio
recording equipment, which then converts the analog
signal to a digital signal.

Bit

A bit is the smallest possible chunk of data memory
used in computer processing and is depicted as either
a 1 or a 0. Bits make up the binary system of the
computer.

Byte

A byte is a chunk of memory that consists of 8 bits; it is
considered to be the best way to indicate computer
memory or storage capacity. In modern computers,
bytes are described in units of megabytes (MB);
gigabytes (GB), where 1 GB equals 1,000 MB; or
terabytes (TB), where 1 TB equals 1 trillion bytes or
1,000 GB. Box 3-2 discusses storage capacities.

BOX 3-2 STORAGE CAPACITIES

Dee McGonigle and Kathleen Mastrian

Storage and memory capacities are evolving. In
the past few decades, there have been great
leaps in data storage. It all begins with the bit,
the basic unit of data storage, composed of 0s
and 1s, also known as binary digits. A byte is
generally considered to be equal to 8 bits. The
files on a computer are stored as binary files.
The software that is used translates these binary
files into words, numbers, pictures, images, or
video. Using this binary code in the binary
numbering system, measurement is counted by
factors of 2, such as 1, 2, 4, 8, 16, 32, 64, and
128. These multiples of the binary system in
computer usage are also prefixed based on the
metric system. Therefore, a kilobyte (KB) is
actually 2 to the 10th power (210) or 1,024
bytes, but is typically considered to be 1,000
bytes. This is why one sees 1,024 or multiples of

that number instead of an even 1,000 mentioned
at times in relation to kilobytes.

In the early 1980s, kilobytes were the norm as
far as computer capacity went, and 128 KB
machines were launched for personal use.
Subsequent decades, however, have seen
advanced computing power and storage
capacity. As capabilities soared, so did the
ability to save and store what was used and
created. Megabytes (MB) emerged as a
common unit of measure; 1 megabyte is
1,048,576 bytes but is considered to be roughly
equivalent to 1 million bytes. The next leap in
computer capacity was one that some people
could not even imagine: gigabytes (GB). A
gigabyte is 1,073,741,824 bytes but is generally
rounded to 1 billion bytes. Some computing
experts are very concerned that valuable bytes
are lost when these measurements are rounded,
whereas hard drive manufacturers use the
decimal system so their capacity is expressed
as an even 1 billion bytes per gigabyte.

Computer capacity has moved into and beyond
the range of terabytes, with capacities moving
into the range of petabytes (PB), exabytes
(EB), zettabytes (ZB), and yottabytes (YB).
These terms for storage capacity are defined as
follows:

1 TB = 1,000 GB

1 PB = 1,000,000 GB

1 EB = 1,000 PB

1 ZB = 1,000 EB

1 YB = 1,000 ZB

To put all of this in perspective, Lyman and
Varian describe the data powers of 10:

2 KB: A typewritten page

2 MB: A high-resolution photograph

10 MB: A minute of high-fidelity sound or a
digital chest X-ray

50 MB: A digital mammogram

1 GB: A symphony in high-fidelity sound or a
movie at TV quality

1 TB: All the X-ray films in a large,
technologically advanced hospital

2 PB: The contents of all U.S. academic
research libraries

5 EB: All words ever spoken by human
beings

We have not even addressed ZB and YB. Stay
tuned . . .

REFERENCE

Lyman, P., & Varian, H. R. (2003).
How much information?
Retrieved from
http://groups.ischool.berkeley.edu/archive/how-
much-info-2003/

Software
Software comprises the application programs
developed to facilitate various user functions, such as
writing, artwork, organizing meetings, surfing the
Internet, communicating with others, and so forth. For
the purposes of this overview, the various types of
software have been divided into four categories: (1) OS
software, (2) productivity software, (3) creativity
software, and (4) communication software.

User friendliness is a critical condition for effective
software adoption. The easier and more intuitive a
software package seems to be to a user influences that
user’s perception of how clear the package is to
understand and to use. The rapid evolution of
hardware mentioned previously has been equally
matched by the phenomenal development in software
over the past three or four decades.

Commercial Software

Several large commercial software companies, such as
Apple, Microsoft, IBM, and Adobe, dominate the
market for software, and have done so since the
advent of the personal computer (PC). Licensed
software has evolved over time; hence, most products
have a long version history. Many software packages,
such as office suites, are expensive to purchase; in
turn, there is a “digital divide” as far as access and
affordability go across societal spheres, especially
when viewed from a global perspective.

Open Source Software

The open source initiative began in the late 1990s and
has become a powerful movement that is changing the
software production and consumer market. In addition
to commercially available software, a growing number
of open source software packages are being
developed in all four of the categories addressed in this
chapter. The open source movement was begun by
developers who wished to offer their creations to others
for the good of the community and encouraged them to
do the same. Users who modify or contribute to the
evolution of open source software are obligated to
share their new code, but essentially the software is
free to all. Apache OpenOffice, Google Docs, and
NeoOffice are examples of open source productivity
software (refer to Figure 3-3).

OS Software

The OS is the most important software on any
computer. It is the very first program to load on
computer start-up and is fundamental for the operation
of all other software and the computer hardware.
Examples of commonly used OSs include the Microsoft
Windows family, Linux, and Mac OS X. The OS
manages both the hardware and the software and
provides a reliable, consistent interface for the software
applications to work with the computer’s hardware. An
OS must be both powerful and flexible to adapt to the
myriad of types of software available, which are made
by a variety of development companies. New versions
of the major OSs are equipped to deal with multiple
users and handle multitasking with ease. For example,
a user can work on a word processing document while
listening for an “email received” signal, have an
Internet browser window open to look for references
on the Internet as needed, listen to music in the CD
drive, and download a file—all at the same time.

OS tasks can be described in terms of six basic
processes:

Memory management
Device management
Processor management
Storage management
Application interface

User interface (usually a graphical user interface
[GUI])

A GUI (pronounced “gooey”) is used by OSs to display
a combination of graphics and text such as icons, drop-
down menus, and buttons; it allows you to use input
and output devices as well as icons that represent files,
programs, actions, and processes.

OSs should be convenient to use, easy to learn,
reliable, safe, and fast. They should also be easy to
design, implement, and maintain and should be
flexible, reliable, error free, and efficient. For example,
Silbershatz, Baer Galvin, and Gagne (2013) described
how “Microsoft’s design goals for Windows included
security, reliability, Windows and POSIX application
compatibility, high performance, extensibility, portability,
and international support” (p. 831). The following goals
were established by Microsoft:

Figure 3-3 Open Source Software

Portability: The OS can be moved from one
hardware architecture to another with few changes
needed.
Security: The OS incorporates hardware protection
for virtual memory and software protection
mechanisms for OS resources, including encryption
and digital signature capabilities.
Portable operating system interface for Unix
(POSIX) compliance: Applicationsdesigned to follow
the POSIX (IEEE 1003.1) standard can be compiled
to run on Windows without changing the source

code. Windows OSs have varying levels of
compatibility with the applications that ran on earlier
versions of Windows OSs.
Multiprocessor support: The OS is designed for
symmetrical multiprocessing.
Extensibility: This capability is provided by using a
layered architecture with a protected executive
layer for basic system services, several server
subsystems that operate in user mode, and a
modular structure that allows additional
environmental subsystems to be added without
affecting the executive layer.
International support: The Windows OS supports
different locales via the national language support
application programming interface (API).
Compatibility with MS-DOS and MS-Windows
applications.

Productivity Software

Productivity software, such as an office suite, is the
type of software most commonly used both in the
workplace and on personal computers. Several
software companies produce this type of multiple-
program software, which usually bundles together
word processing, spreadsheet, database,
presentation, Web development, and email programs.

The intent of office suites is generally to provide all of
the basic programs that office or knowledge workers

need to do their work. The bundled programs within the
suite are organized to be compatible with one another,
are designed to look similar to one another for ease of
use, and provide a powerful array of tools for data
manipulation, information gathering, and knowledge
generation. Some office suites add other programs,
such as database creation software, mathematical
editors, drawing, and desktop publishing programs.
Table 3-1 summarizes the application of programs
included in some of the popular office suites: Microsoft
Office, Apache OpenOffice, NeoOffice, Corel
WordPerfect Suite, and Apple iWork.

Table 3-1 Office Suite Software Features and
Examples

Office Suite Software

Program Application Examples

Word

processing

Composition, editing,

formatting, and

producing text

documents

Microsoft Word, Open

Office Writer, KOffice

KWord, Corel Word

Perfect or Corel Write,

Apple Pages

Spreadsheets Grid-based documents in

ledger format; organizes

numbers and text;

calculates statistical

formulae

Microsoft Excel, Open

Office Calc, KOffice

KSpread, Corel Quattro

Pro, Apple Numbers

Presentations Slideshow software,

usually used for business

or classroom

presentations using text,

images, graphs, media

Microsoft Power

Point, Open Office

Impress, KOffice

KPresenter, Corel

Show, Apple Keynote

Databases Database creation for

text and numbers

Microsoft Access (in

elite packages), Open

Office Base, KOffice

Kexi, Corel Calculate,

Corel Paradox

Email Integrated email program

to send and receive

electronic mail

Microsoft Outlook,

Corel Word

Perfect Mail, Mozilla

Thunderbird

Drawing Graphics and diagram

drawing

Open Office Draw,

Corel Presentation

Graphics, KOffice Kivio,

Karbon, Krita

Math

formulas

Inserts math equations in

word processing and

presentation work

Open Office Math,

KOffice KFormula

Desktop

publishing

Page layouts and

publication-ready

documents

Microsoft Publisher (in

elite packages), Apple

Pages

Creative Software

Creative software includes programs that allow users
to draw, paint, render, record music and sound, and
incorporate digital video and other multimedia in

professional aesthetic ways to share and convey
information and knowledge (Table 3-2).

Table 3-2 Creative Software Features and Examples

Creative Software

Program and Application Software Examples

Raster graphics programs

Draw, paint, render, manipulate, and

edit images, fonts, and photographs to

create pixel-based (dot points) digital

art and graphics.

Adobe Photoshop and

Fireworks, Ulead Photo

Impact, Corel Draw, Painter,

and Paint Shop Pro, GIMP

(open source), KOffice Krita

(open source)

Vector graphics programs

Mathematically rendered, geometric

modeling is applied through shapes,

curves, lines, and points and

manipulated for shape, color, and

size. Ideal for printing and three-

dimensional (3D) modeling.

Adobe Flash, Freehand,

and Illustrator; Corel

Draw and Designer, Open

Office Draw (open source),

Mirosoft Visio, Xara Xtreme,

KOffice Karbon14 (open

source)

Desktop publishing programs

Page layout and publishing

preparation for printed and Web

documents, such as magazines,

journals, books, newsletters, and

brochures.

Adobe InDesign, Corel

Page

Maker, Microsoft Publisher,

Scribus (open source),

QuarkXPress, Apple Pages

(note that many of the

graphics programs can also

be used for DTP)

Web design programs

Create, edit, and update webpages

using specific codes, such as XML,

CSS, HTML, and Java.

Adobe Dreamweaver,

Coffee Cup, Microsoft

FrontPage, Nvu (open

source), W3C’s Amaya

(open source)

Multimedia programs

Combines text, audio, images,

animation, and video into interactive

content for electronic presentation.

Adobe Flash, Microsoft

Movie Maker, Apple Quick

Time and FinalCut Studio,

Corel VideoStudio, Ulead

VideoStudio, Real Studio,

CamStudio (open source),

Audacity (open source)

Communication Software

Networking and communication software enable
users to dialogue, share, and network with other users
via the exchange of email or instant message (IM), by
accessing the World Wide Web, or by engaging in
virtual meetings using conferencing software (Table
3-3)

Table 3-3 Communication Software Features and
Examples

Communication Software

Email client

Allows user to read, edit, forward,

and send email messages to other

users via an Internet connection.

The software can be resident on the

computer or accessed via the World

Wide Web.

Resident programsMicrosoft

Outlook and Outlook Express,

Eudora, Pegasus, Mozilla

Thunderbird, Lotus

NotesWeb-based

programsGmail, Yahoo Mail,

Hotmail

Internet browsers

Enables user to access, browse,

download, upload, and interact with

text, audio, video, and other Web-

based documents.

Mozilla Firefox, Microsoft

Internet Explorer, Google

Chrome, Apple Safari, Opera,

Microbrowser (for mobile

access)

Instant messaging (IM)

Real-time text messaging between

users, can attach images, videos,

and other documents via personal

computer, cell phone, handheld

devices.

MSN Instant Messenger,

Microsoft Live Messenger,

Yahoo Messenger, Apple

iChat

Conferencing

Enables user to communicate in a

virtual meeting room setting to share

work, discussions, planning, using

an intranet or Internet environment;

can exhibit files, video, and

screenshots of content.

Adobe Acrobat Connect,

Microsoft Live Meeting or

Meeting Space,

GoToMeeting, Meeting

Bridge, Free Conference,

RainDance, WebEx

Acquisition of Data and Information:
Input Components
Input devices include the keyboard; mouse; joysticks
(typically used for playing computer games); game
controllers or pads; Web cameras (webcams); stylus
(often used with tablets or personal digital assistants);
image scanners for copying a digital image of a
document or picture; touch pads; or other plug-and-
play input devices, such as digital cameras, digital
video recorders (camcorders), MP3 players, electronic
musical instruments, and physiologic monitors. These
devices are the origin or medium used to input text,
visual, audio, or multimedia data into the computer
system for viewing, listening, manipulating, creating, or
editing. The primary input devices on a computer are
the keyboard, mouse, touch pad, and touch screen.

Keyboard

A computer keyboard is very similar to the typewriter
keyboards of earlier days and usually serve as the
prime input device that enables the user to type words,
numbers, and commands into the computer’s
programs. Standard computer keyboards have 110
keys and are organized to facilitate Latin-based
languages using a QWERTY layout (so named
because these letters appear on the first six keys in the
first row of letters).

Certain keys are used as command keys, particularly
the control (CTRL), alternate (Alt), delete (Del), and
shift keys, which can all be used to activate useful
commands. The escape (ESC) key allows the user
instantly to exit a process or program. The F keys,
numbered F1 through F12, are function keys. They are
used in different ways by particular programs. If a
program instructs users to press the “F8” key, they
would do so by pressing F8. The print screen (PrtSc)
key sends a graphical picture or screen shot of a
computer screen to the clipboard. This copied screen
shot can then be pasted in any graphic program that
can work with bitmap files.

Some keyboards have a wire and plug in, while others
are wireless or cordless. Touch screen or virtual
keyboards are those being incorporated into the touch
screens of phones, gaming machines, and tablets, and
they are also available through ease-of-access tools on
laptops.

Mouse

The mouse is the second-most-commonly used input
device. It is manipulated by the user’s hand to point,
click, and move objects around on the computer
screen. A mouse can come in a number of different
configurations, including a standard mechanical
trackball serial mouse, bus mouse, PS/2 mouse, USB-
connected mouse, optical lens mouse, cordless

mouse, and optomechanical mouse. Even though “the
mouse may be a simple device in concept,” it has
evolved and increased in complexity and capability
over time (Bagaza & Westover, 2016, para. 2). For
example, “[g]aming mice take the basic mouse concept
and amplify every element to extremes” (Bagaza &
Westover, para. 4). Some manufacturers offer
specialized features, but there is a common
“combination of high-performance parts—laser
sensors, light-click buttons, and gold-plated USB
connectors—and customization, like adjustable weight,
programmable macro commands, and on-the-fly DPI
switching. For non-gamers, these features are overkill;
for dedicated gamers, they provide a competitive edge”
(Bagaza & Westover, para. 4). The dots per inch
(DPI) switch is an actual switch on a computer mouse
that allows you to adjust the mouse’s sensitivity to
movement, as in faster or slower mouse pointer
speeds. Having the ability to do this on the fly or as
needed without pausing could enhance the computing
or gaming experience.

Touch Pad

The touch pad is a device that senses the pressure of
the user’s finger along with the movement of the finger
on the touch pad to control input positioning. It is an
alternative to using a mouse.

Touch Screen

The touch screen is a display used as an input device
for interacting with or relating to the display’s materials
or content. The user can touch or press on the
designated display area to respond, execute, or
request information or output.

Processing of Data and Information:
Throughput/Processing Components
All of the hardware discussed earlier in this chapter is
involved in the throughput or processing of input
data and in the preparation of output data and
information. Specific software is used, depending on
the application and data involved. One key hardware
component, the computer monitor, is a unique example
of a visible throughput component—it is the part of the
computer that users focus on the most when they are
working on a computer. Input data can be visualized
and accessed by manipulating the mouse and
keyboard input devices, but it is the monitor that
receives the user’s attention. The monitor is critical for
the efficient rendering during this part of the cycle,
because it facilitates user access and control of the
data and information.

Monitor

The monitor is the visual display that serves as the
landscape for all interactions between user and
machine. It typically resembles a television screen, and

comes in various sizes (usually ranging from 15 to 21
inches) and configurations. Monitors either are based
on cathode ray tubes (the conventional monitor with a
large section behind the screen) or are thinner, flat-
screen liquid crystal display devices. Some computer
monitors also have a touch screen that can serve as an
input device when the user touches specific areas of
the screen.

Monitors vary in their refresh rate (usually measured in
megahertz) and dot pitch. Both of these characteristics
are important for user comfort. The faster the refresh
rate, the cleaner and clearer the image on the screen,
because the monitor refreshes the screen contents
more frequently. For example, a monitor with a 100
MHz refresh rate refreshes the screen contents 100
times per second. Similarly, the larger the dot pitch
factor, the smaller the dots that make up the screen
image, which provides a more detailed display on the
monitor and also facilitates clarity and ease of viewing.

If equipped with a touch screen, a monitor can also
serve as an input device when activated by a stylus or
finger pressure. Some users might also consider the
monitor to be an output device, because access to
input and stored documents is often performed via the
screen (e.g., reading a document that is stored on the
computer or viewable from the Internet). As we
advance to more engaged computing, larger screens

and ultra-wide monitors are evolving to provide
immersive experiences.

Smartphone displays can be a form of AMOLED
(Active Matrix Organic Light-Emitting Diode) or IPS
LCD (In-Plane Switching Liquid Crystal Display). In
the AMOLED type, the individual pixels are lit
separately (active matrix); the next-generation super
AMOLED type includes touch sensors. The IPS LCD–
type uses polarized light passing through a color filter
and all of the pixels are backlit. The liquid crystals
control the brightness and which pixels are on or off.
With the active matrix, you have crisp, vivid colors and
darker blacks.

Dissemination: Output Components
Output devices carry data in a usable form through exit
devices in or attached to a computer. Common forms
of output include printed documents, audio or video
files, physiologic summaries, scan results, and saved
files on portable disk drives, such as a CD, DVD, flash
drive, or external hard drive. Output devices literally put
data and information at the user’s fingertips, which can
then be used to develop knowledge and even wisdom.
The most commonly used output devices include
printers, speakers, and portable disk drives.

Printer

Printers are external components that can be attached
to a computer using a printer cord that is secured into
the computer’s printer port. Printers enable users to
print a hard paper copy of documents that are housed
on the computer.

The most common printer types are the inkjet and laser
printers. Inkjet printers are more economical to use and
offer good quality print; they apply ink to paper using a
jet-spray mechanism. Laser printers produce publisher-
ready quality printing if combined with good-quality
paper, but cost more in terms of printing supplies. Both
types of printers can print in black and white or in color.
Printers can be single function (print only), but typically
they are all-in-one machines or multifunction printers
that can also scan, fax, and copy. There are printers
that can be accessed via the Internet using Wi-Fi.
There are also three-dimensional (3D) printers that can
create a 3D solid object produced layer by layer from a
3D software digital file.

Speakers

All computers have some sort of speaker setup, usually
small speakers embedded in the monitor, in the case,
or, if a laptop, close to the keyboard. Often, external
speakers are added to a computer system using
speaker connectors; these devices provide enhanced
sound and a more enjoyable listening experience.

What Is the Relationship of
Computer Science to
Knowledge?
Scholars and researchers are beginning to understand
the effects that computer systems, architecture,
applications, and processes have on the potential for
knowledge acquisition and development. Users who
have access to contemporary computers equipped with
full Internet access have resources at their fingertips
that were only dreamed of before the 21st century.
Entire library collections are accessible, with many
documents available in full printable form. Users are
also able to contribute to the development of
knowledge through the use of productivity, creativity,
and communication software. In addition, using the
World Wide Web (WWW) interface, users are able to
disseminate knowledge on a grand scale with other
users. This deluge of information available via
computers must be mastered and organized by the
user if knowledge is to emerge. Discernment and the
ability to critique and filter this information must also be
present to facilitate the further development of wisdom.

The development of an understanding of computer
science principles as they apply to technology used in
nursing can facilitate optimal usage of the technology
for knowledge development in the profession. The
maxim that “knowledge is power” and that the skillful

use of computers lies at the heart of this power is a
presumption. Once nurses become comfortable with
the various technologies, they can shape them, refine
them, and apply them in new and different ways, just
as they have always adapted earlier equipment and
technologies. Nurses must harness the power of data
and information through the use of computer
technologies to build knowledge and gain wisdom.

How Does the Computer
Support Collaboration and
Information Exchange?
Computers can be linked to other computers through
networking software and hardware to promote
communication, information exchange, work sharing,
and collaboration. Such networks can be local or
organizationally based, with computers joined together
into a local area network; organized on a wider area
scope (e.g., a city or district) using a metropolitan area
network; or encompassing computers at an even
greater distance (e.g., a whole country or continent, or
the Internet itself) using a wide area network
configuration (Sarkar, 2006). Network interface cards
are used to connect a computer and its modem to a
network.

Networks within health care can manifest in several
different configurations, including client-focused

networks, such as in telenursing, e-health, and client
support networks; work-related networks, including
virtual work and virtual social networks; and learning
and research networks, as in communities of practice.
These trends are still evolving in most nursing work
environments (and most nurses’ personal lives), but
they are predicted to continue to grow dramatically. We
are experiencing one of the greatest upsurges in
shared information and our ability to access, exchange,
and utilize this information to enhance knowledge.

Virtual social networks are another form of professional
network that have expanded phenomenally since the
advent of the Internet and other computer software and
hardware. Nursing-related virtual social networks
provide a cyberspace for nurses to make contacts,
share information and ideas, and build a sense of
community.

Social communication software is used to provide a
dynamic virtual environment, and often virtual social
networks provide communicative capabilities through
posting tools, such as blogs, forums, and wikis; email
for sharing ideas on a smaller scale; collaborative
areas for interaction, creating, and building digital
artifacts or planning projects; navigation tools for
moving through the virtual network landscape; and
profiles to provide a space for each member to disclose
personal information with others. Nurses who have to
engage in shift work often find that virtual social

networks can provide a sense of connection with other
professionals that is available around the clock.
Because time is often a factor in any social
interchange, virtual communication offers an alternative
for practicing nurses, who can access information and
engage in interchanges at any time of day. With active
participation, the interchanges and shared information
and ideas of the network can culminate in valuable
social and cultural capital, available to all members of
that network. Often, nursing virtual social networks are
created for the purpose of exchanging ideas on
practice issues and best practices; to become more
knowledgeable about new trends, research, and
innovations in health care; or to participate in
advocacy, activist, and educational initiatives.

Through the use of portable disk devices, such as flash
drives, CDs, and DVDs, as well as Web-based and
cloud spaces, people can share information,
documents, and communications by exchanging files.
Since the advent of the Internet in the mid-1980s, the
World Wide Web has evolved to become a viable and
user-friendly way for people to collaborate and
exchange information, projects, and other knowledge-
based files, such as websites, email, social networking
applications, and webinar logs. Box 3-3 provides
information on Web 2.0, the latest iteration of the World
Wide Web, and beyond.

BOX 3-3 WEB 2.0 AND BEYOND TOOLS

Dee McGonigle, Kathleen Mastrian, and Wendy
Mahan

Web 2.0—the name given to the new World
Wide Web tools—enables users to collaborate,
network socially, and disseminate knowledge
with other users on a scale that was once not
even comprehensible. These programs promote
data and information exchange, feedback, and
knowledge development and dissemination.

To facilitate a selective review of the Web 2.0
tools available, they have been categorized into
three areas here: (1) tools for creating and
sharing information, (2) tools for collaborating,
and (3) tools for communicating. Examples of
tools for creating and sharing information
include blogs, podcasts, Flickr, YouTube,
Hellodeo, Jing, Screencast-o-matic, Facebook,
MySpace, Box, Samepage, Wrike, Snapchat,
and MakeBeliefsComix. Examples of tools for
collaborating with others include Google Docs,
Zoho, wikis, Del.icio.us, and Gliffy. Finally, some
tools for communicating with others include
Adobe Connect, GoToMeeting, BlueJeans,
WebEx Meeting Center, Vyew, Skype, Twitter,
and instant messaging.

The application of the creating and sharing
information tools has led to an explosion of
social networking on the Web. YouTube has
promoted the “broadcast yourself” proliferation.
Anyone can post a video onto YouTube that is
shared with others over the Web. Similarly,
Flickr allows users to upload and tag personal
photos to share either privately or publicly.
Facebook and MySpace both promote
socializing on the Web. Facebook is a social
utility and MySpace is a place for friends,
according to the descriptions found on these
websites. Other tools let users create and share
recorded messages, diagrams, screen captures,
and even custom comic strips.

Collaborating over the Web has become easier.
Indeed, it is a way of life for many people.
Google Docs and Zoho allow users to create
online and share and collaborate in real time.
Wikis are server-based software programs that
enable users to generate and edit webpage
content using any browser. Del.icio.us is a social
bookmarking manager that uses tags to identify
or describe the bookmarks that can be shared
with others.

Communicating with others includes audio- and
videoconferencing in real time. Adobe Connect
is a comprehensive Web communications
solution. Although a fee-based service, it does

provide a free trial. Users should read all of the
documentation on Adobe’s site before
downloading, installing, and using this software.
Vyew is free, always-on collaboration plus live
webinars. Skype allows users to make calls in
audio only or with video. Users can download
Skype for free but depending on the type of calls
made, fees or charges could be assessed.
Individuals should read through all of the
information before downloading, installing, and
using this software. Twitter allows participants to
answer the question “What are you doing?” with
messages containing 140 or fewer characters.
Although Twitter can be used to keep the friends
in a person’s network updated on daily activities,
it can also be used for other purposes, such as
asking questions or expressing thoughts. In
addition, Twitter can be accessed by cell
phones, so users can stay in touch on the go.

Along with all of the advantages and intellectual
harvesting capabilities from the use of these
tools come serious security issues. Wagner
(2007) warned the user to “bear in mind before
you jump in that you’re giving information to a
third-party company to store” (para. 5). He also
states that “you should talk to your company’s
legal and compliance offices to be sure you’re
obeying the law and regulations with regard to
managing company’s information” (para. 5). One

suggestion that Wagner offers is that if you do
not want to involve a third party, “Wikis provide a
good alternative for organizations looking to
maintain control of their own software.
Organizations can install wiki software on their
own, internal servers” (para. 6).

This new wave of Web-based tools facilitates
the ability to interact, exchange, collaborate,
communicate, and share in ways that have only
begun to be realized. As the tools and their
innovative uses continue to expand, users need
to stay vigilant to handle the associated security
challenges. These Web 2.0 and beyond tools
are providing a new cyber-playground that is
limited only by users’ own imaginations and
intelligence. We encourage you to explore these
tools.

REFERENCE

Wagner, M. (2007). Nine easy Web-
based collaborative tools.
Forbes. Retrieved from
http://www.forbes.com/2007/02/26/google-
microsoft-bluetie-enttech-
cx_mw_0226smallbizresource.html

Cloud Computing
Cloud computing has Web browser–based login-
accessible data, software, and hardware that you can
access and use. Using the cloud, you could link
systems together and reduce costs (Figure 3-4).
According to Griffith (2016), “cloud computing means
storing and accessing data and programs over the
Internet instead of [on] your computer’s hard drive. The
cloud is just a metaphor for the Internet” (para. 2). IBM
(2016) stated that cloud computing, “referred to as
simply ‘the cloud,’ is the delivery of on-demand
computing resources—everything from applications to
data centers—over the Internet on a pay-for-use basis”
(para. 1). IBM described services as elastic resources,
either metered or self-service. Elastic resources refer
to those that are able to be scaled up or down to meet
the consumer’s needs. Metered services allow you to
pay only for what you use, and self-service refers to
having self-service access to all of the IT resources the
consumer needs. Woodford (2016) stated that cloud
computing is different because it is managed; on-
demand; and can be public, private, or a hybrid of both.
The public cloud is owned and operated by
companies offering public access to computing
resources. It is believed to be more affordable and
economically sound because the user does not need to
purchase the hardware, software, or supporting
infrastructure, as these are managed and owned by the
cloud provider (IBM, 2016). The private cloud is

operated for a single organization with the
infrastructure being managed and/or hosted internally
or outsourced to a third party; it provides added control
and avoids multi-tenancy (IBM).

As we explore Web-based apps and computing over
the Internet, we are cloud computing. Griffith (2016)
described some common major examples of cloud
computing that you might be using right now: Google
Drive, Microsoft Office Online, Microsoft OneDrive,
Apple iCloud, Amazon Cloud Drive, Box, Dropbox, and
SugarSync. There is also cloud hardware; the primary
example of a device that is completely cloud-centric is
the Chromebook, a laptop that has just enough local
storage and power to run the Chrome OS, which
essentially turns the Google Chrome Web browser into
an operating system. “With a Chromebook, most
everything you do is online: apps, media, and storage
are all in the cloud” (Griffith, 2016, para. 16).

Figure 3-4 Cloud Computing

Cloud storage is data storage provided by networked
online servers that are typically outside of the institution
whose data are being housed.

There are also additional services based in the cloud
that are mainly business related: software as a
service (SaaS), platform as a service (PaaS), and
infrastructure as a service (IaaS) (Figure 3-5). SaaS,
such as Salesforce.com refers to cloud-based
applications with the following benefits: quickly start
using innovative or specific business apps that are
scalable to your needs, any connected computer can
access the apps and data, and data is not lost if your
hard drive crashes because the data is stored in the

cloud (Griffith, 2016; IBM, 2016). PaaS provides
everything needed to support the cloud application’s
building and delivery, enabling users to develop and
launch custom Web applications rapidly to the cloud
(Griffith, 2016; IBM, 2016). IaaS such as Amazon,
Microsoft, Google, and Rackspace provide a rentable
backbone to companies, enabling the scalable, on-
demand infrastructure they need to support their
dynamic workloads; the user pays only for what they
use and he or she does not have to invest in hardware
such as networks, storage, and data center space
(Griffith, 2016; IBM, 2016). You can access and
receive services from Netflix and Pinterest because
they are customers of Amazon’s cloud services.
According to Griffith (2016), cloud computing is truly
big business and could generate 500 billion dollars
within the next 5 years.

Figure 3-5 Software as a Service (SaaS), Platform as
a Service (PaaS), and Infrastructure as a Service
(IaaS)

Cloud computing is Internet computing, and it has the
same pitfalls and benefits as using the Internet. Some
are not sold on the claims that it is totally reliable, safe,
and/or secure. Others believe it is a more
environmentally friendly option because it uses fewer
resources and less energy, and yet many people can
share efficiently managed, centralized cloud-based
systems (Woodford, 2016). One of the driving forces
behind the initiation of cloud computing was the need
for scalable resources that are affordable. As with
anything on the Internet, these resources can be
shared or privately held. Cloud computing will continue

to grow as long as there is demand and it can meet the
scalability requirements while maintaining secure,
reliable spaces.

In an ideal world, nurses would be able to use and
interact with computer technologies effectively to
enhance patient care. They would understand
computer science and know how to harness its
capabilities to benefit the profession and ultimately
their patients.

Looking to the Future
The use of the cloud will continue to expand. The
market for wearable technology, which is comprised
of smaller and faster handheld and portable computer
systems, and high-quality voice-activated inventions
will further facilitate the use of computers in nursing
practice and professional development. The field of
computer science will continue to contribute to the
evolving art and science of nursing informatics. New
trends promise to bring wide-sweeping and (it is
hoped) positive changes to the practice of nursing.
Computers and other technologies have the potential
to support a more client-oriented healthcare system in
which clients truly become active participants in their
own healthcare planning and decisions. Mobile health
technology, telenursing, sophisticated electronic health
records, and next-generation technology are predicted
to contribute to high-quality nursing care and

consultation within healthcare settings, including
patients’ homes and communities.

Computers are becoming more powerful, yet more
compact, which will contribute to the development of
several technologic initiatives that are currently still in
their infancy, such as quantum computing. Some of
these initiatives are described here. These predicted
innovations are only some of the many computer and
technologic applications being developed. As nurses
gain proficiency in capitalizing on the creative,
timesaving, and interactive capabilities emerging from
information technology research, the field of nursing
informatics will grow in similar proportions.

Quantum Computing
Quantum bits (qubits) are three-dimensional arrays of
atoms in quantum states. A quantum computer is a
proposed machine that is not based on the binary
system, but instead performs calculations based on the
behavior of subatomic particles or qubits. It is
estimated that if quantum computing, the act of using a
quantum computer, is ever realized, we will be able to
execute millions of instructions per second (MIPS)
due to the qubits existing in more than one state at a
time or having the ability to simultaneously execute and
process. According to Kennedy (2016), “the era of
quantum computers is one step closer” (para. 1) due to
the creation of qubits by David Weiss’s research team.

Voice-Activated Communicators
Voice-activated communicators are already on the
market, with new iterations being developed by a
variety of companies, including Vocera
Communications. Vocera (2015) developed the Vocera
B3000n Communication Badge, which

is a lightweight, voice-controlled,
wearable device that enables instant two-
way or one to many conversations using
intuitive and simple commands. The
Vocera Badge is widely used by mobile
workers who need wearable devices that
provide the convenience and expedience
of being able to respond to calls without
pressing a button (i.e. sterile operating
rooms, nuclear power plants, hotel staff,
security personnel). (para. 1)

These new technologies will permit nurses to use
wireless, hands-free devices to communicate with one
another and to record data. This technology is
becoming a user-friendly and cost-effective way to
increase clinical productivity.

Game and Simulation Technology
Game and simulation technology is offering realistic,
innovative ways to teach content in general, including

healthcare informatics concepts and skills. The same
technology that powers video games is being used to
create dynamic educational interfaces to help students
learn about pathophysiology, care guidelines, and a
host of other topics. Such applications are also very
valuable for client education and health promotion
materials. The “serious games” industry is growing now
that video game producers are looking beyond mere
entertainment to address public and private policy,
management, and leadership issues and topics,
including those related to health care. For example, the
Games for Health Project, initiated by the Robert Wood
Johnson Foundation (2015), is working on developing
best practices to support innovation in healthcare
training, messaging, and illness management. The
Serious Games & VE Arcade & Showcase is presented
at the annual meetings of the Society for Simulation in
Healthcare and is continuing to flourish with numerous
products available to demonstrate.

Virtual Reality
Virtual reality is another technological breakthrough
that is and will continue to influence healthcare
education and professional development. Virtual reality
is a three-dimensional, computer-generated “world”
where a person (with the right equipment) can move
about and interact as if he or she was actually in the
visualized location. The person’s senses are immersed
in this virtual reality world using special gadgetry, such

as head-mounted displays, data gloves, joysticks, and
other hand tools. The equipment and special
technology provide a sense of presence that is lacking
in multimedia and other complex programs. According
to Smith (2015), “It’s crazy but true: Virtual reality will
be a real thing in people’s homes by this time next
year” (para. 1). There are numerous products
available. Virtual Realities (2015) stated that they
provide “head mounted displays, head trackers, motion
trackers, data gloves, 3D controllers, haptic devices,
stereoscopic 3D displays, VR domes and virtual reality
software. Virtual Realities’ products are used by
government, educational, industrial, medical and
entertainment markets worldwide” (para. 1). Oculus VR
(2015) developed Rift, which is the next generation of
virtual reality products, and they are currently
distributing the developer kits. HTC (2015)
manufactures consumer electronics and developed the
Vive headset. The Morpheus headset is used with
PlayStation 4.

Mobile Devices
Mobile devices will be used more by nurses both at the
point of care and in planning, documenting, interacting
with the interprofessional healthcare team, and
research. Nurses also will be using such powerful
wearable technologies as nano-based diagnostic
sensors in their personal lives, and will be generating
their own data streams and receiving data from the

wearable and mobile devices their patients use.
Silbershatz et al. (2013) stated that Apple iOS and
Google Android are “currently dominating mobile
computing” (p. 37). Perry (2015) stated that it is
“estimated more than 177 million wearable devices will
be in use by 2018” (para. 5). Cisco (2014) reported that
“by the year 2020, the majority of Generation X and Y
professionals believe that smartphones and wearable
devices will be the workforce’s most important
‘connected’ device—while the laptop remains the
workplace device of choice” (para. 1). Data are truly at
our fingertips.

Summary
The field of computer science is one of the fastest-
growing disciplines. Astonishing innovations in
computer hardware, software, and architecture have
occurred over the past few decades, and there are no
indications that this trend will come to a halt anytime
soon. Computers have increased in speed, accuracy,
and efficiency, yet now cost less and have reduced
physical size compared to their forebears. These
trends are predicted to continue. Current computer
hardware and software serve as vital and valuable
tools for both nurses and patients to engage in on-
screen and online activities that provide rich access to
data and information. Productivity, creativity, and
communication software tools also enable nurses to
work with computers to further foster knowledge

acquisition and development. Wide access to vast
stores of information and knowledge shared by others
facilitates the emergence of wisdom in users, which
can then be applied to nursing in meaningful and
creative ways. It is imperative that nurses become
discerning, yet skillful users of computer technology to
apply the principles of nursing informatics to practice to
improve patient care and to contribute to the
profession’s ever-growing body of knowledge.

Working Wisdom
Since the beginning of the profession, nurses have
applied their ingenuity, resourcefulness, and
professional awareness of what works to adapt
technology and objects to support nursing care, usually
with the intention of promoting efficiency but also in
support of client comfort and healing. This
resourcefulness could also be applied effectively to the
adaptation of information technology within the care
environment, to ensure that the technology truly does
serve clients and nurses and the rest of the
interprofessional team.

Consider this question: “How can you develop
competency in using the various computer hardware
and software not only to promote efficient, high-quality
nursing care and to develop yourself professionally, but
also to further the development of the profession’s
body of knowledge?”

Application Scenario
Dan P. is a first-year student in graduate studies in
nursing. In the past, he has learned to use his family’s
personal computer to surf the World Wide Web,
exchange email with friends, and play some computer
games. Now, however, Dan realizes that the computer
is a vital tool for his academic success. He has saved
up enough money to purchase a laptop computer. He
has decided on an Intel processor with 1 TB of storage
and 8 GB of RAM. Dan also wishes to choose
appropriate software for his system. He is on a limited
budget but wants to make the most of his investment.

1. Dan still wants to learn more about computers.
You recommend that he review the following
information: Domingo (2016), Knapp (2016), and
PCMag Digital Group (2016).

2. Which of the four categories of software
discussed in this chapter would benefit Dan the
most in his studies (OS, productivity, creativity,
or communication)? Dan definitely needs an OS
—this is critical. He would also directly benefit
from productivity software and at least
connective email and web browser software
from the communication group so he can access
the Internet for research, to collaborate with
peers, and to communicate with his teachers.

3. How could Dan afford to install software from all
four groups on his new laptop? If Dan accessed

some open source software (e.g., Apache
OpenOffice for his productivity software), he
could save money to put toward creativity
software.

THOUGHT-PROVOKING QUESTIONS

1. How can knowledge of computer
hardware and software help nurses to
participate in information technology
adoption decisions in the practice area?

2. How can new computer software help
nurses engage in professional
development, collaboration, and
knowledge dissemination activities at their
own pace and leisure?

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Sarkar, N. (2006). Tools for teaching
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Silbershatz, A., Baer Galvin, P., & Gagne,
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computing-introduction.html

CHAPTER 4: Introduction
to Cognitive Science and
Cognitive Informatics

Kathleen Mastrian and Dee McGonigle

Objectives
1. Describe cognitive science.
2. Assess how the human mind processes

and generates information and
knowledge.

3. Explore cognitive informatics.
4. Examine artificial intelligence and its

relationship to cognitive science and
computer science.

Key Terms
» Artificial intelligence

» Brain

» Cognitive informatics

» Cognitive science

» Computer science

» Connectionism

» Decision making

» Empiricism

» Epistemology

» Human Mental Workload (MWL)

» Intelligence

» Intuition

» Knowledge

» Logic

» Memory

» Mind

» Neuroscience

» Perception

» Problem solving

» Psychology

» Rationalism

» Reasoning

» Wisdom

Introduction
Cognitive science is the fourth of four basic building
blocks used to understand informatics (Figure 4-1).
The Building Blocks of Nursing Informatics section
began by examining nursing science, information
science, and computer science, and considering how
each relates to and helps one understand the concept
of informatics. This chapter explores the building
blocks of cognitive science, cognitive informatics
(CI), and artificial intelligence (AI).

Figure 4-1 Building Blocks of Nursing Informatics

Throughout the centuries, cognitive science has
intrigued philosophers and educators alike. Beginning
in Greece, the ancient philosophers sought to
comprehend how the mind works and what the nature
of knowledge is. This age-old quest to unravel the
processes inherent in the working brain has been
undertaken by some of the greatest minds in history.
However, it was only about 50 years ago that computer
operations and actions were linked to cognitive
science, meaning theories of the mind, intellect, or

brain. This association led to the expansion of cognitive
science to examine the complete array of cognitive
processes, from lower-level perceptions to higher-level
critical thinking, logical analysis, and reasoning.

The focus of this chapter is the impact of cognitive
science on nursing informatics (NI). This section
provides the reader with an introduction and overview
of cognitive science, the nature of knowledge, wisdom,
and AI as they apply to the Foundation of Knowledge
model and NI. The applications to NI include problem
solving, decision support systems, usability issues,
user-centered interfaces and systems, and the
development and use of terminologies.

Cognitive Science
The interdisciplinary field of cognitive science studies
the mind, intelligence, and behavior from an
information-processing perspective. H. Christopher
Longuet-Higgins originated the term “cognitive science”
in his 1973 commentary on the Lighthill report, which
pertained to the state of AI research at that time. The
Cognitive Science Society and the Cognitive Science
Journal date back to 1980 (Cognitive Science
Society, 2005). Their interdisciplinary base arises from
psychology, philosophy, neuroscience, computer
science, linguistics, biology, and physics; covers
memory, attention, perception, reasoning, language,
mental ability, and computational models of cognitive

processes; and explores the nature of the mind,
knowledge representation, language, problem solving,
decision making, and the social factors influencing the
design and use of technology. Simply put, cognitive
science is the study of the mind and how information is
processed in the mind. As described in the Stanford
Encyclopedia of Philosophy (2010):

The central hypothesis of cognitive
science is that thinking can best be
understood in terms of representational
structures in the mind and computational
procedures that operate on those
structures. While there is much
disagreement about the nature of the
representations and computations that
constitute thinking, the central hypothesis
is general enough to encompass the
current range of thinking in cognitive
science, including connectionist theories
which model thinking using artificial
neural networks. (para. 9)

Connectionism is a component of cognitive science
that uses computer modeling through artificial neural
networks to explain human intellectual abilities. Neural
networks can be thought of as interconnected simple
processing devices or simplified models of the brain
and nervous system that consist of a considerable

number of elements or units (analogs of neurons)
linked together in a pattern of connections (analogs of
synapses). A neural network that models the entire
nervous system would have three types of units: (1)
input units (analogs of sensory neurons), which receive
information to be processed; (2) hidden units (analogs
to all of the other neurons, not sensory or motor), which
work in between input and output units; and (3) output
units (analogs of motor neurons), where the outcomes
or results of the processing are found.

Connectionism (Figure 4-2) is rooted in how
computation occurs in the brain and nervous system or
biologic neural networks. On their own, single neurons
have minimal computational capacity. When
interconnected with other neurons, however, they have
immense computational power. The connectionism
system or model learns by modifying the connections
linking the neurons. Artificial neural networks are
unique computer programs designed to model or
simulate their biologic analogs, the neurons of the
brain.

Figure 4-2 Connectionism

The mind is frequently compared to a computer, and
experts in computer science strive to understand how
the mind processes data and information. In contrast,
experts in cognitive science model human thinking
using artificial networks provided by computers—an
endeavor sometimes referred to as AI. How does the
mind process all of the inputs received? Which items
and in which ways are things stored or placed into
memory, accessed, augmented, changed,

reconfigured, and restored? Cognitive science provides
the scaffolding for the analysis and modeling of
complicated, multifaceted human performance and has
a tremendous effect on the issues impacting
informatics.

The end user is the focus of this activity because the
concern is with enhancing the performance in the
workplace; in nursing, the end user could be the actual
clinician in the clinical setting, and cognitive science
can enhance the integration and implementation of the
technologies being designed to facilitate this
knowledge worker with the ultimate goal of improving
patient care delivery. Technologies change rapidly, and
this evolution must be harnessed for the clinician at the
bedside. To do this at all levels of nursing practice, one
must understand the nature of knowledge, the
information and knowledge needed, and the means by
which the nurse processes this information and
knowledge in the situational context.

Sources of Knowledge
Just as philosophers have questioned the nature of
knowledge, so they have also strived to determine how
knowledge arises, because the origins of knowledge
can help one understand its nature. How do people
come to know what they know about themselves,
others, and their world? There are many viewpoints on
this issue, both scientific and nonscientific.

According to Holt (2006), “There are two competing
traditions concerning the ultimate source of our
knowledge: empiricism and rationalism” (para. 3).
Empiricism is based on knowledge being derived from
experiences or senses, whereas rationalism contends
that “some of our knowledge is derived from reason
alone and that reason plays an important role in the
acquisition of all of our knowledge” (para. 5).
Empiricists do not recognize innate knowledge,
whereas rationalists believe that reason is more
essential in the acquisition of knowledge than the
senses.

Three sources of knowledge have been identified: (1)
instinct, (2) reason, and (3) intuition. Instinct is when
one reacts without reason, such as when a car is
heading toward a pedestrian and he jumps out of the
way without thinking. Instinct is found in both humans
and animals, whereas reason and intuition are found
only in humans. Reason “[c]ollects facts, generalizes,
reasons out from cause to effect, from effect to cause,
from premises to conclusions, from propositions to
proofs” (Sivananda, 2004, para. 4). Intuition is a way
of acquiring knowledge that cannot be obtained by
inference, deduction, observation, reason, analysis, or
experience. Intuition was described by Aristotle as “[a]
leap of understanding, a grasping of a larger concept
unreachable by other intellectual means, yet
fundamentally an intellectual process” (Shallcross &
Sisk, 1999, para. 4).

Some believe that knowledge is acquired through
perception and logic. Perception is the process of
acquiring knowledge about the environment or situation
by obtaining, interpreting, selecting, and organizing
sensory information from seeing, hearing, touching,
tasting, and smelling. Logic is “[a] science that deals
with the principles and criteria of validity of inference
and demonstration: the science of the formal principles
of reasoning” (Merriam-Webster Online Dictionary,
2007, para. 1). Acquiring knowledge through logic
requires reasoned action to make valid inferences.

The sources of knowledge provide a variety of inputs,
throughputs, and outputs through which knowledge is
processed. No matter how one believes knowledge is
acquired, it is important to be able to explain or
describe those beliefs, communicate those thoughts,
enhance shared understanding, and discover the
nature of knowledge.

Nature of Knowledge
Epistemology is the study of the nature and origin of
knowledge—that is, what it means to know. Everyone
has a conception of what it means to know based on
their own perceptions, education, and experiences;
knowledge is a part of life that continues to grow with
the person. Thus a definition of knowledge is
somewhat difficult to agree on because it reflects the

viewpoints, beliefs, and understandings of the person
or group defining it. Some people believe that
knowledge is part of a sequential learning process
resembling a pyramid, with data on the bottom, rising
to information, then knowledge, and finally wisdom.
Others believe that knowledge emerges from
interactions and experience with the environment, and
still others think that it is religiously or culturally bound.
Knowledge acquisition is thought to be an internal
process derived through thinking and cognition or an
external process from senses, observations, studies,
and interactions. Descartes’s important premise “called
‘the way of ideas’ represents the attempt in
epistemology to provide a foundation for our
knowledge of the external world (as well as our
knowledge of the past and of other minds) in the
mental experiences of the individual” (Encyclopedia
Britannica, 2007, para. 4).

For the purpose of this text, knowledge is defined as
the awareness and understanding of a set of
information and ways that information can be made
useful to support a specific task or arrive at a decision.
It abounds with others’ thoughts and information or
consists of information that is synthesized so that
relationships are identified and formalized.

How Knowledge and Wisdom
Are Used in Decision Making

The reason for collecting and building data,
information, and knowledge is to be able to make
informed, judicious, prudent, and intelligent decisions.
When one considers the nature of knowledge and its
applications, one must also examine the concept of
wisdom. Wisdom has been defined in numerous ways:

Knowledge applied in a practical way or translated
into actions
The use of knowledge and experience to heighten
common sense and insight to exercise sound
judgment in practical matters
The highest form of common sense resulting from
accumulated knowledge or erudition (deep,
thorough learning) or enlightenment (education that
results in understanding and the dissemination of
knowledge)
The ability to apply valuable and viable knowledge,
experience, understanding, and insight while being
prudent and sensible
Focused on our own minds
The synthesis of our experience, insight,
understanding, and knowledge
The appropriate use of knowledge to solve human
problems

In essence, wisdom entails knowing when and how to
apply knowledge. The decision-making process
revolves around knowledge and wisdom. It is through
efforts to understand the nature of knowledge and its

evolution to wisdom that one can conceive of, build,
and implement informatics tools that enhance and
mimic the mind’s processes to facilitate decision
making and job performance.

Cognitive Informatics
Wang (2003) described CI as an emerging
transdisciplinary field of study that bridges the gap in
understanding regarding how information is processed
in the mind and in the computer. Computing and
informatics theories can be applied to help elucidate
the information processing of the brain, and cognitive
and neurologic sciences can likewise be applied to
build better and more efficient computer processing
systems. Wang suggested that the common issue
among the human knowledge sciences is the drive to
develop an understanding of natural intelligence and
human problem solving.

Pacific Northwest National Laboratory (PNNL), an
organization operated on behalf of the U.S.
Department of Energy, suggested the disciplines of
neuroscience, linguistics, AI, and psychology constitute
this field. PNNL (2008) defined CI as “the
multidisciplinary study of cognition and information
sciences, which investigates human information
processing mechanisms and processes and their
engineering applications in computing” (para. 1). CI
helps to bridge this gap by systematically exploring the

mechanisms of the brain and mind and exploring
specifically how information is acquired, represented,
remembered, retrieved, generated, and communicated.
This dawning of understanding can then be applied
and modeled in AI situations resulting in more efficient
computing applications.

Wang (2003) explained further:

Cognitive informatics attempts to solve
problems in two connected areas in a
bidirectional and multidisciplinary
approach. In one direction, CI uses
informatics and computing techniques to
investigate cognitive science problems,
such as memory, learning, and
reasoning; in the other direction, CI uses
cognitive theories to investigate the
problems in informatics, computing, and
software engineering. (p. 120)

Principles of cognitive informatics and an
understanding of how humans interact with computers
can be used to build information technology (IT)
systems that better meet the needs of users (Figure 4-
3). If a system is too complex or too taxing for a user,
he or she is likely to resist its use. The National Center
for Cognitive Informatics and Decision Making in
Healthcare (NCCD) was established to respond to “the

urgent and long-term cognitive challenges in health IT
adoption and meaningful use. NCCD’s vision is to
become a national resource that provides strategic
leadership in patient-centered cognitive support
research and applications in health care”
(HealthIT.gov, 2013, para. 1). Similarly, Longo (2015)
emphasized Human Mental Workload (MWL) as a
key component in effective system design (Figure 4-4).
He stated,

Figure 4-3 Cognitive Informatics Leads to Usable
Systems

Figure 4-4 Human Mental Workload

At a low level of MWL, people may often
experience annoyance and frustration
when processing information. On the
other hand, a high level can also be both
problematic and even dangerous, as it
leads to confusion, decreases
performance in information processing
and increases the chances of errors and
mistakes. (p. 758)

Cognitive Informatics and

Nursing Practice
According to Mastrian (2008), the recognition of the
potential application of principles of cognitive science
to NI is relatively new. The traditional and widely
accepted definition of NI advanced by Graves and
Corcoran (1989) is that NI is a combination of nursing
science, computer science, and information science
used to describe the processes nurses use to manage
data, information, and knowledge in nursing practice.
Turley (1996) proposed the addition of cognitive
science to this mix, as nurse scientists are seen to
strive to capture and explain the influence of the
human brain on data, information, and knowledge
processing and to elucidate how these factors in turn
affect nursing decision making. The need to include
cognitive sciences is imperative as researchers attempt
to model and support nursing decision making in
complex computer programs.

In 2003, Wang proposed the term cognitive informatics
to signify the branch of information and computer
sciences that investigates and explains information
processing in the human brain. The science of CI grew
out of interest in AI, as computer scientists developed
computer programs that mimic the information
processing and knowledge generation functions of the
human brain. CI bridges the gap between artificial and
natural intelligence and enhances the understanding of
how information is acquired, processed, stored, and

retrieved so that these functions can be modeled in
computer software.

What does this have to do with nursing? At its very
core, nursing practice requires problem solving and
decision making. Nurses help people manage their
responses to illnesses and identify ways that patients
can maintain or restore their health. During the nursing
process, nurses must first recognize that there is a
problem to be solved, identify the nature of the
problem, pull information from knowledge stores that is
relevant to the problem, decide on a plan of action,
implement the plan, and evaluate the effectiveness of
the interventions. When a nurse has practiced the
science of nursing for some time, he or she tends to do
these processes automatically; it is instinctively known
what needs to be done to intervene in the problem.
What happens, however, if the nurse faces a situation
or problem for which he or she has no experience on
which to draw? The ever-increasing acuity and
complexity of patient situations coupled with the
explosion of information in health care has fueled the
development of decision support software embedded in
the electronic health record. This software models the
human and natural decision-making processes of
professionals in an artificial program. Such systems
can help decision makers to consider the
consequences of different courses of action before
implementing the action. They also provide stores of
information that the user may not be aware of and can

use to choose the best course of action and ultimately
make a better decision in unfamiliar circumstances.

Decision support programs continue to evolve as
research in the fields of cognitive science, AI, and CI is
continuously generated and then applied to the
development of these systems. Nurses must embrace
—not resist—these advances as support and
enhancement of the practice of nursing science.

What Is AI?
The field of AI deals with the conception, development,
and implementation of informatics tools based on
intelligent technologies. This field captures the complex
processes of human thought and intelligence.

Herbert Simon believes that the field of AI could have
two functions: “One is to use the power of computers to
augment human thinking, just as we use motors to
augment human or horse power. . . . The other is to
use a computer’s artificial intelligence to understand
how humans think. In a humanoid way” (Stewart,
1994, para. 13). According to the AAAI (2014), AI is the
“scientific understanding of the mechanisms underlying
thought and intelligent behavior and their embodiment
in machines” (para. 1).

John McCarthy, one of the men credited with founding
the field of AI in the 1950s, stated that AI “is the

science and engineering of making intelligent
machines, especially intelligent computer programs. It
is related to the similar task of using computers to
understand human intelligence, but AI does not have to
confine itself to methods that are biologically
observable” (2007, p. 2).

Lamont (2007) interviewed Ray Kurzweil, a visionary
who defined AI as “the ability to perform a task that is
normally performed by natural intelligence, particularly
human natural intelligence. We have in fact artificial
intelligence that can perform many tasks that used to
require—and could only be done by—human
intelligence” (para. 6). The intelligence factor is
extremely important in AI and has been defined by
McCarthy as “the computational part of the ability to
achieve goals in the world. Varying kinds and degrees
of intelligence occur in people, many animals, and
some machines” (2007, p. 2).

The challenge of this field rests in capturing, mimicking,
and creating the complex processes of the mind in
informatics tools, including software, hardware, and
other machine technologies, with the goal that the tool
be able to initiate and generate its own mechanical
thought processing. The brain’s processing is highly
intricate and complicated. This complexity is reflected
in Cohn’s (2006) comment that “Artificial intelligence is
50 years old this summer, and while computers can
beat the world’s best chess players, we still can’t get

them to think like a 4-year-old” (para. 1). AI uses
cognitive science and computer science to replicate
and generate human intelligence. This field will
continue to evolve and produce artificially intelligent
tools to enhance nurses’ personal and professional
lives.

AI in the Future
As electronic health records become more ubiquitous
and we have access to physiologic data streamed in
real time, we will have the potential to process large
amounts of data using AI tools and we will begin to see
data analytics that will enable machine processing that
far exceeds the capabilities of the human mind.
According to Neill (2013),

Perhaps the next great challenge for AI in
healthcare is to develop approaches that
can be applied to the entire population of
patients monitoring huge quantities of
data to automatically detect threats to
patient safety (including patterns of
suboptimal care, as well as outbreaks of
hospital acquired illness), and to discover
new best practices of patient care. (p. 93)

Summary

Cognitive science is the interdisciplinary field that
studies the mind, intelligence, and behavior from an
information-processing perspective. CI is a field of
study that bridges the gap in understanding regarding
how information is processed in the mind and in the
computer. Computing and informatics theories can be
applied to help elucidate the information processing of
the brain, and cognitive and neurologic sciences can
likewise be applied to build better and more efficient
computer processing systems.

AI is the field that deals with the conception,
development, and implementation of informatics tools
based on intelligent technologies. This field captures
the complex processes of human thought and
intelligence. AI uses cognitive science and computer
science to replicate and generate human intelligence.

The sources of knowledge, nature of knowledge, and
rapidly changing technologies must be harnessed by
clinicians to enhance their bedside care. Therefore, we
must understand the nature of knowledge, the
information and knowledge needed, and the means by
which nurses process this information and knowledge
in their own situational context. The reason for
collecting and building data, information, and
knowledge is to be able to build wisdom—that is, the
ability to apply valuable and viable knowledge,
experience, understanding, and insight while being
prudent and sensible. Wisdom is focused on our own

minds, the synthesis of our experience, insight,
understanding, and knowledge. Nurses must use their
wisdom and make informed, judicious, prudent, and
intelligent decisions while providing care to patients,
families, and communities. Cognitive science, CI, and
AI will continue to evolve to help build knowledge and
wisdom.

THOUGHT-PROVOKING QUESTIONS

1. How would you describe CI? Reflect on a
plan of care that you have developed for
a patient. How could CI be used to create
tools to help with or support this important
work?

2. Think of a clinical setting with which you
are familiar and envision how AI tools
might be applied in this setting. Are there
any current tools in use? Which current or
emerging tools would enhance practice in
this setting and why?

3. Use your creative mind to think of a tool
of the future based on cognitive
informatics that would support your
practice.

References

Association for the Advancement of
Artificial Intelligence (AAAI). (2014).
Homepage. Retrieved from
http://www.aaai.org

Cognitive Science Society. (2005). CSJ
archive. Retrieved from
http://www.cogsci.rpi.edu/CSJarchive/1980v04/index.html

Cohn, D. (2006). AI reaches the golden
years. Wired. Retrieved from
http://archive.wired.com/science/discoveries/news/2006/07/71389

Encyclopedia Britannica. (2007).
Epistemology. Retrieved from
http://www.britannica.com/eb/article-
247960/epistemology

Graves, J., & Corcoran, S. (1989). The
study of nursing informatics. Image:
Journal of Nursing Scholarship, 21(4),
227–230.

HealthIT.gov. (2013). National center for
cognitive informatics and decision
making in healthcare. Retrieved from

https://www.healthit.gov/policy-
researchers-implementers/national-
center-cognitive-informatics-and-
decision-making-healthcare

Holt, T. (2006). Sources of knowledge.
Retrieved from
http://www.theoryofknowledge.info/sourcesofknowledge.html

Lamont, I. (2007). The grill: Ray Kurzweil
talks about “augmented reality” and the
singularity. Computer World. Retrieved
from
http://www.computerworld.com/action/article.do?
command=viewArticleBasic&articleId=306176

Longo, L. (2015). A defeasible reasoning
framework for human mental workload
representation and assessment.
Behaviour & Information Technology,
34(8), 758–786.
doi:10.1080/0144929X.2015.1015166

Longuet-Higgins, H. C. (1973). Comments
on the Lighthill report and the
Sutherland reply. Artificial Intelligence:
A Paper Symposium, 35–37.

Mastrian, K. (2008, February). Invited
editorial: Cognitive informatics and
nursing practice. Online Journal of
Nursing Informatics, 12(1). Retrieved
from http://ojni.org/12_1/kathy.html

McCarthy, J. (2007). What is artificial
intelligence? Retrieved from
http://www.formal.stanford.edu/jmc/whatisai.pdf

Merriam-Webster Online Dictionary.
(2007). Logic. Retrieved from
http://www.merriam-
webster.com/dictionary/logic

Neill, D. (2013). Using artificial intelligence
to improve hospital inpatient care.
IEEE Intelligent Systems, 92–95.

Pacific Northwest National Laboratory,
U.S. Department of Energy. (2008).
Cognitive informatics. Retrieved from
http://www.pnl.gov/coginformatics

Shallcross, D. J., & Sisk, D. A. (1999).
What is intuition? In T. Arnold (Ed.),
Hyponoesis glossary: Intuition.
Retrieved from
http://www.hyponoesis.org/Glossary/Definition/Intuition

Sivananda, S. (2004). Four sources of
knowledge. The Divine Life Society.
Retrieved from
http://www.dlshq.org/messages/knowledge.htm

Stanford Encyclopedia of Philosophy.
(2010). Cognitive science. Retrieved
from
http://plato.stanford.edu/entries/cognitive-
science

Stewart, D. (1994). The creator of the first
thinking machine on the future of
artificial intelligence: Herbert Simon on
the mind in the machine. OMNI Q&A.
Retrieved from
http://www.omnimagazine.com/archives/interviews/simon/index.html

Turley, J. (1996). Toward a model for
nursing informatics. Image: Journal of
Nursing Scholarship, 28(4), 309–313.

Wang, Y. (2003). Cognitive informatics: A
new transdisciplinary research field.
Brain and Mind, 4(2), 115–127.

CHAPTER 5: Ethical
Applications of
Informatics

Dee McGonigle, Kathleen Mastrian, and Nedra Farcus

Objectives
1. Recognize ethical dilemmas in nursing

informatics.
2. Examine ethical implications of nursing

informatics.
3. Evaluate professional responsibilities for

the ethical use of healthcare informatics
technology.

4. Explore the ethical model for ethical
decision making.

5. Analyze practical ways of applying the
ethical model for ethical decision making
to manage ethical dilemmas in nursing
informatics.

Key Terms
» Alternatives

» Antiprinciplism

» Applications (Apps)

» Autonomy

» Beneficence

» Bioethics

» Bioinformatics

» Care ethics

» Casuist approach

» Confidentiality

» Consequences

» Courage

» Decision making

» Decision support

» Duty

» Ethical decision making

» Ethical dilemma

» Ethical, social, and legal implications

» Ethicists

» Ethics

» Eudaemonistic

» Fidelity

» Good

» Google Glass

» Harm

» Justice

» Liberty

» Moral dilemmas

» Moral rights

» Morals

» Negligence

» Nicomachean

» Nonmaleficence

» Principlism

» Privacy

» Rights

» Security

» Self-control

» Smartphones

» Social media

» Standards

» Truth

» Uncertainty

» Values

» Veracity

» Virtue

» Virtue ethics

» Wisdom

Introduction
Those who followed the actual events of Apollo 13, or
who were entertained by the movie (Howard, 1995),
watched the astronauts strive against all odds to bring
their crippled spaceship back to Earth. The speed of
their travel was incomprehensible to most viewers, and
the task of bringing the spaceship back to Earth
seemed nearly impossible. They were experiencing a
crisis never imagined by the experts at NASA, and they
made up their survival plan moment by moment. What
brought them back to Earth safely? Surely, credit must
be given to the technology and the spaceship’s ability

to withstand the trauma it experienced. Most amazing,
however, were the traditional nontechnological tools,
skills, and supplies that were used in new and different
ways to stabilize the spacecraft’s environment and
keep the astronauts safe while traveling toward their
uncertain future.

This sense of constancy in the midst of change serves
to stabilize experience in many different life events and
contributes to the survival of crisis and change. This
rhythmic process is also vital to the healthcare
system’s stability and survival in the presence of the
rapidly changing events of the Knowledge Age. No one
can dispute the fact that the Knowledge Age is
changing health care in ways that will not be fully
recognized and understood for years. The change is
paradigmatic, and every expert who addresses this
change reminds healthcare professionals of the need
to go with the flow of rapid change or be left behind.

As with any paradigm shift, a new way of viewing the
world brings with it some of the enduring values of the
previous worldview. As health care continues its
journey into digital communications, telehealth, and
wearable technologies, it brings some familiar tools
and skills recognized in the form of values, such as
privacy, confidentiality, autonomy, and
nonmaleficence. Although these basic values remain
unchanged, the standards for living out these values
will take on new meaning as health professionals

confront new and different moral dilemmas brought on
by the adoption of technological tools for information
management, knowledge development, and evidence-
based changes in patient care. Ethical decision-making
frameworks will remain constant, but the context for
examining these moral issues or ethical dilemmas will
become increasingly complex.

This chapter highlights some familiar ethical concepts
to consider on the challenging journey into the
increasingly complex future of healthcare informatics.
Ethics and bioethics are briefly defined, and the
evolution of ethical approaches from the Hippocratic
ethic era, to principlism, to the current antiprinciplism
movement of ethical decision making is examined.
New and challenging ethical dilemmas are surfacing in
the venture into the unfolding era of healthcare
informatics (Figure 5-1). Also presented in this chapter
are findings from some of the more recent literature
related to these issues. Readers are challenged to
think constantly and carefully about ethics as they
become involved in healthcare informatics and to stay
abreast of new developments in ethical approaches.

Figure 5-1 Ethics in Health Care

Ethics
Ethics is a process of systematically examining
varying viewpoints related to moral questions of right
and wrong. Ethicists have defined the term in a variety
of ways, with each reflecting a basic theoretical
philosophic perspective.

Beauchamp and Childress (1994) referred to ethics as
a generic term for various ways of understanding and
examining the moral life. Ethical approaches to this
examination may be normative, presenting standards
of right or good action; descriptive, reporting what

people believe and how they act; or explorative,
analyzing the concepts and methods of ethics.

Husted and Husted (1995) emphasized a practice-
based ethics, stating “ethics examines the ways men
and women can exercise their power in order to bring
about human benefit—the ways in which one can act in
order to bring about the conditions of happiness” (p. 3).

Velasquez, Andre, Shanks, and Myer (1987) posed the
question, “What is ethics?”, and answered it with the
following two-part response: “First, ethics refers to well-
based standards of right and wrong that prescribe what
humans ought to do, usually in terms of rights,
obligations, benefits to society, fairness, or specific
virtues” (para. 10), and “Secondly, ethics refers to the
study and development of one’s ethical standards”
(para. 11).

Regardless of the theoretical definition, common
characteristics regarding ethics are its dialectical, goal-
oriented approach to answering questions that have
the potential for multiple acceptable answers.

Bioethics
Bioethics is defined as the study and formulation of
healthcare ethics. Bioethics takes on relevant ethical
problems experienced by healthcare providers in the
provision of care to individuals and groups. Husted and

Husted (1995) state the fundamental background of
bioethics that forms its essential nature is:

1. The nature and needs of humans as living,
thinking beings

2. The purpose and function of the healthcare
system in a human society

3. An increased cultural awareness of human
beings’ essential moral status (p. 7)

Bioethics emerged in the 1970s as health care began
to change its focus from a mechanistic approach of
treating disease to a more holistic approach of treating
people with illnesses. As technology advanced,
recognition and acknowledgment of the rights and the
needs of individuals and groups receiving this high-
tech care also increased.

In today’s technologically savvy healthcare
environment, patients are being prescribed
applications (apps) for their smartphones instead of
medications in some clinical practices. Patients’
smartphones are being used to interact with them in
new ways and to monitor and assess their health in
some cases. With apps and add-ons, for example, a
provider can see the patient’s ECG immediately, or the
patient can monitor his or her ECG and send it to the
provider as necessary. Another example would be a
sensor attached to the patient’s mobile device that
could monitor blood glucose levels. We are just

beginning to realize the vast potential of these mobile
devices—and the threats they sometimes pose.
Google Glass, for example, can take photos and
videos (Stern, 2013) without anyone knowing that this
is occurring; in the healthcare environment, such a
technological advancement can violate patients’
privacy and confidentiality. Wearable technologies
provide a data-rich environment for diagnosing,
addressing, and monitoring health issues. As we
analyze huge patient datasets, concerns arise about
privacy, confidentiality, and data sharing (Johns
Hopkins, Berman Institute of Bioethics, n.d.). Add these
evolving developments to healthcare providers’
engagement in social media use with their patients,
and it becomes clear that personal and ethical
dilemmas abound for nurses in the new über-
connected world.

Ethical Issues and Social
Media
As connectivity has improved owing to emerging
technologies, a rapid explosion in the phenomenon
known as social media has occurred. Social media is
defined as “a group of Internet-based applications that
build on the ideological and technological foundations
of Web 2.0 and that allow the creation and exchange of
user-generated content” (Spector & Kappel, 2012, p.
1). Just as the electronic health record serves as a

real-time event in recording patient–provider contact,
so the use of social media represents an instantaneous
form of communication. Healthcare providers—
particularly nurses—can enhance the patient care
delivery system, promote professional collegiality, and
provide timely communication and education regarding
health-related matters by using this forum (National
Council of State Boards of Nursing [NCSBN], 2011,
p. 1). In all cases, however, nurses must exercise
judicious use of social media to protect patients’ rights.
Nurses must understand their obligation to their chosen
profession, particularly as it relates to personal
behavior and the perceptions of their image as
portrayed through social media. Above all, nurses must
be mindful that once communication is written and
posted on the Internet, there is no way to retract what
was written; it is a permanent record that can be
tracked, even if the post is deleted (Englund, Chappy,
Jambunathan, & Gohdes, 2012, p. 242).

Social media platforms include such electronic
communication outlets as Facebook, Twitter, LinkedIn,
Snapchat, and YouTube. Other widely used means of
instantaneous communications include wikis, blogs,
tweeting, Skype, and the “hangout” feature on
Google+. Even as recently as 5 years ago, some of
these means of exchanging information were unknown
(Spector & Kappel, 2012, p. 1).

Use of social networking has increased dramatically

among all age groups. Zephoria (2016) reported that,
in 2016, Facebook had over 1.65 billion active monthly
users worldwide as compared to 955 million active
monthly users in 2012, and users spend an average of
20 minutes on Facebook per visit. Twitter’s influence
on health care continues to grow, with Symplur (2016)
reporting 1,603,327,260 tweets, including healthcare-
related Tweet chats, conferences, and diseases such
as breast cancer, diabetes, and irritable bowel
syndrome.

The rapid growth of social media has found many
healthcare professionals unprepared to face the new
challenges or to exploit the opportunities that exist with
these forums. The need to maintain confidentiality
presents a major obstacle to the healthcare industry’s
widespread adoption of such technology; thus social
networking has not yet been fully embraced by many
health professionals (Anderson, 2012, p. 22). Englund
and colleagues (2012) noted that undergraduate
nursing students may face ambiguous and
understudied professional and ethical implications
when using social networking venues.

Another confounding factor is the increased use of
mobile devices by health professionals as well as the
public (Swartz, 2011, p. 345). Smartphones have the
capability to take still pictures as well as live
recordings; they have found their way into treatment
rooms around the globe.

As a consequence of more stringent confidentiality
laws and more widespread availability and use of
social and mobile media, numerous ethical and legal
dilemmas have been posed to nurses. What are not
well defined are the expectations of healthcare
providers regarding this technology. In some cases,
nurses employed in the emergency department (ED)
setting have been subjected to video and audio
recordings by patients and families when they perform
procedures and give care during the ED visit. Nurses
would be wise to inquire—before an incident occurs—
about the hospital policy regarding audio/video
recording by patients and families, as well as the state
laws governing two-party consent. Such laws require
consent of all parties to any recording or
eavesdropping activity (Lyons & Reinisch, 2013, p.
54).

Sometimes the enthusiasm for patient care and
learning can lead to ethics violations. In one case, an
inadvertent violation of privacy laws occurred when a
nurse in a small town blogged about a child in her care
whom she referred to as her “little handicapper.” The
post also noted the child’s age and the fact that the
child used a wheelchair. A complaint about this breach
of confidentiality was reported to the Board of Nursing.
A warning was issued to the nurse blogging this
information, although a more stringent disciplinary

action could have been taken (Spector & Kappel,
2012, p. 2).

In another case cited by Spector and Kappel (2012), a
student nurse cared for a 3-year-old leukemia patient
whom she wanted to remember after finishing her
pediatric clinical experience. She took the child’s
picture, and in the background of the photo the
patient’s room number was clearly displayed. The
child’s picture was posted on the student nurse’s
Facebook page, along with her statement of how much
she cared about this child and how proud she was to
be a student nurse. Someone forwarded the picture to
the nurse supervisor of the children’s hospital. Not only
was the student expelled from the program, but the
clinical site offer made by the children’s hospital to the
nursing school was rescinded. In addition, the hospital
faced citations for violations of the Health Insurance
Portability and Accountability Act (HIPAA) owing to the
student nurse’s transgression (p. 3).

Nurses sometimes use social network sites or blog
about the patients they care for believing that if they
omit the patient’s name, they are not violating the
patient’s privacy and confidentiality. “A nurse who posts
about caring for an 85-year-old female in her city could
cause the patient to be identified by content in the post.
This action does not protect the patient” (Henderson &
Dahnke, 2015, p. 63). A white paper published by the

NCSBN (2011) provides a thorough discussion of the
issues associated with nurses’ use of social media.

Ethical Dilemmas and Morals
An ethical dilemma arises when moral issues raise
questions that cannot be answered with a simple,
clearly defined rule, fact, or authoritative view. Morals
refer to social convention about right and wrong human
conduct that is so widely shared that it forms a stable
(although usually incomplete) communal consensus
(Beauchamp & Childress, 1994). Moral dilemmas
arise with uncertainty, as is the case when some
evidence a person is confronted with indicates an
action is morally right and other evidence indicates that
this action is morally wrong. Uncertainty is stressful
and, in the face of inconclusive evidence on both sides
of the dilemma, causes the person to question what he
or she should do. Sometimes the individual concludes
that based on his or her moral beliefs, he or she cannot
act. Uncertainty also arises from unanticipated effects
or unforeseeable behavioral responses to actions or
the lack of action. Adding uncertainty to the situational
factors and personal beliefs that must be considered
creates a need for an ethical decision-making model to
help one choose the best action.

Ethical Decision Making

Ethical decision making refers to the process of
making informed choices about ethical dilemmas
based on a set of standards differentiating right from
wrong. This type of decision making reflects an
understanding of the principles and standards of ethical
decision making, as well as the philosophic
approaches to ethical decision making, and it requires
a systematic framework for addressing the complex
and often controversial moral questions.

As the high-speed era of digital communications
evolves, the rights and the needs of individuals and
groups will be of the utmost concern to all healthcare
professionals. The changing meaning of
communication, for example, will bring with it new
concerns among healthcare professionals about
protecting patients’ rights of confidentiality, privacy, and
autonomy. Systematic and flexible ethical decision-
making abilities will be essential for all healthcare
professionals.

Notably, the concept of nonmaleficence (“do no harm”)
will be broadened to include those individuals and
groups whom one may never see in person, but with
whom one will enter into a professional relationship of
trust and care. Mack (2000) has discussed the
popularity of individuals seeking information online
instead of directly from their healthcare providers and
the effects this behavior has on patient–provider
relationships. He is emphatic in his reminder that

“organizations and individuals that provide health
information on the Internet have obligations to be
trustworthy, provide high-quality content, protect users’
privacy, and adhere to standards of best practices for
online commerce and online professional services in
healthcare” (p. 41).

RESEARCH BRIEF

Using an online survey of 1,227 randomly
selected respondents, Bodkin and Miaoulis
(2007) sought to describe the characteristics of
information seekers on e-health websites, the
types of information they seek, and their
perceptions of the quality and ethics of the
websites. Of the respondents, 74% had sought
health information on the Web, with women
accounting for 55.8% of the health information
seekers. A total of 50% of the seekers were
between 35 and 54 years of age. Nearly two
thirds of the users began their searches using a
general search engine rather than a health-
specific site, unless they were seeking
information related to symptoms or diseases.
Top reasons for seeking information were
related to diseases or symptoms of medical
conditions, medication information, health news,
health insurance, locating a doctor, and
Medicare or Medicaid information. The level of
education of information seekers was related to

the ratings of website quality, in that more
educated seekers found health information
websites more understandable, but were more
likely to perceive bias in the website information.
The researchers also found that the ethical
codes for e-health websites seem to be
increasing consumers’ trust in the safety and
quality of information found on the Web, but that
most consumers are not comfortable purchasing
health products or services online.

The full article appears in Bodkin, C., & Miaoulis, G. (2007).

eHealth information quality and ethics issues: An exploratory

study of consumer perceptions. International Journal of

Pharmaceutical and Healthcare Marketing, 1(1), 27–42.

Retrieved from ABI/INFORM Global (Document ID:

1515583081).

Makus (2001) suggests that both autonomy and justice
are enhanced with universal access to information, but
that tensions may be created in patient–provider
relationships as a result of this access to outside
information. Healthcare workers need to realize that
they are no longer the sole providers and gatekeepers
of health-related information; ideally, they should
embrace information empowerment and suggest
websites to patients that contain reliable, accurate, and
relevant information (Resnick, 2001).

It is clear that patients’ increasing use of the Internet
for healthcare information may prompt entirely new
types of ethical issues, such as who is responsible if a
patient is harmed as a result of following online health
advice. Derse and Miller (2008) discuss this issue
extensively and conclude that a clear line separates
information and practice. Practice occurs when there is
direct or personal communication between the provider
and the patient, when the advice is tailored to the
patient’s specific health issue, and when there is a
reasonable expectation that the patient will act in
reliance on the information.

A summit sponsored by the Internet Healthcare
Coalition (www.ihealthcoalition.org) in 2000
developed the E-Health Code of Ethics (eHealth code,
n.d.), which includes eight standards for the ethical
development of health-related Internet sites: (1)
candor, (2) honesty, (3) quality, (4) informed consent,
(5) privacy, (6) professionalism, (7) responsible
partnering, and (8) accountability. For more information
about each of these standards, access the full
discussion of the E-Health Code of Ethics
(http://www.ihealthcoalition.org/ehealth-code-of-
ethics).

It is important to realize that the standards for ethical
development of health-related Internet sites are
voluntary; there is no overseer perusing these sites
and issuing safety alerts for users. Although some sites

carry a specific symbol indicating that they have been
reviewed and are trustworthy (HONcode and Trust-e),
the healthcare provider cannot control which
information patients access or how they perceive and
act related to the health information they find online.
The research brief on the previous page describes one
study of consumer perceptions of health information on
the Web.

Theoretical Approaches to
Healthcare Ethics
Theoretical approaches to healthcare ethics have
evolved in response to societal changes. In a 30-year
retrospective article for the Journal of the American
Medical Association, Pellegrino (1993) traced the
evolution of healthcare ethics from the Hippocratic
ethic, to principlism, to the current antiprinciplism
movement.

The Hippocratic tradition emerged from relatively
homogenous societies where beliefs were similar and
most societal members shared common values. The
emphasis was on duty, virtue, and gentlemanly
conduct.

Principlism arose as societies became more
heterogeneous and members began experiencing a
diversity of incompatible beliefs and values; it emerged

as a foundation for ethical decision making. Principles
were expansive enough to be shared by all rational
individuals, regardless of their background and
individual beliefs. This approach continued into the
1900s and was popularized by two bioethicists,
Beauchamp and Childress (1977; 1994), in the last
quarter of the 20th century. Principles are considered
broad guidelines that provide guidance or direction but
leave substantial room for case-specific judgment.
From principles, one can develop more detailed rules
and policies.

Beauchamp and Childress (1994) proposed four
guiding principles: (1) respect for autonomy, (2)
nonmaleficence, (3) beneficence, and (4) justice.

Autonomy refers to the individual’s freedom from
controlling interferences by others and from
personal limitations that prevent meaningful
choices, such as adequate understanding. Two
conditions are essential for autonomy: liberty,
meaning the independence from controlling
influences, and the individual’s capacity for
intentional action.
Nonmaleficence asserts an obligation not to inflict
harm intentionally and forms the framework for the
standard of due care to be met by any professional.
Obligations of nonmaleficence are obligations of not
inflicting harm and not imposing risks of harm.
Negligence—a departure from the standard of due

care toward others—includes intentionally imposing
risks that are unreasonable and unintentionally but
carelessly imposing risks.
Beneficence refers to actions performed that
contribute to the welfare of others. Two principles
underlie beneficence: Positive beneficence requires
the provision of benefits, and utility requires that
benefits and drawbacks be balanced. One must
avoid negative beneficence, which occurs when
constraints are placed on activities that, even
though they might not be unjust, could in some
situations cause detriment or harm to others.
Justice refers to fair, equitable, and appropriate
treatment in light of what is due or owed to a
person. Distributive justice refers to fair, equitable,
and appropriate distribution in society determined
by justified norms that structure the terms of social
cooperation.

Beauchamp and Childress also suggest three types of
rules for guiding actions: substantive, authority, and
procedural. (Rules are more restrictive in scope than
principles and are more specific in content.)
Substantive rules are rules of truth telling,
confidentiality, privacy, and fidelity, and those
pertaining to the allocation and rationing of health care,
omitting treatment, physician-assisted suicide, and
informed consent. Authority rules indicate who may
and should perform actions. Procedural rules establish
procedures to be followed.

The principlism advocated by Beauchamp and
Childress has since given way to the antiprinciplism
movement, which emerged in the 21st century with the
expansive technological changes and the tremendous
rise in ethical dilemmas accompanying these changes.
Opponents of principlism include those who claim that
its principles do not represent a theoretical approach
as well as those who claim that its principles are too far
removed from the concrete particularities of everyday
human existence; are too conceptual, intangible, or
abstract; or disregard or do not take into account a
person’s psychological factors, personality, life history,
sexual orientation, or religious, ethnic, and cultural
background. Different approaches to making ethical
decisions are next briefly explored, providing the
reader with an understanding of the varied methods
professionals may use to arrive at an ethical decision.

The casuist approach to ethical decision making grew
out of the call for more concrete methods of examining
ethical dilemmas. Casuistry is a case-based ethical
reasoning method that analyzes the facts of a case in a
sound, logical, and ordered or structured manner. The
facts are compared to decisions arising out of
consensus in previous paradigmatic or model cases.
One casuist proponent, Jonsen (1991), prefers
particular and concrete paradigms and analogies over
the universal and abstract theories of principlism.

The Husted bioethical decision-making model centers
on the healthcare professional’s implicit agreement
with the patient or client (Husted & Husted, 1995). It is
based on six contemporary bioethical standards: (1)
autonomy, (2) freedom, (3) veracity, (4) privacy, (5)
beneficence, and (6) fidelity.

The virtue ethics approach emphasizes the virtuous
character of individuals who make the choices. A
virtue is any characteristic or disposition desired in
others or oneself. It is derived from the Greek word
aretai, meaning “excellence,” and refers to what one
expects of oneself and others. Virtue ethicists
emphasize the ideal situation and attempt to identify
and define ideals. Virtue ethics dates back to Plato and
Socrates. When asked “whether virtue can be taught or
whether virtue can be acquired in some other way,
Socrates answers that if virtue is knowledge, then it
can be taught. Thus, Socrates assumes that whatever
can be known can be taught” (Scott, 2002, para. 9).
According to this view, the cause of any moral
weakness is not a matter of character flaws but rather
a matter of ignorance. In other words, a person acts
immorally because the individual does not know what
is really good for him or her. A person can, for example,
be overpowered by immediate pleasures and forget to
consider the long-term consequences. Plato
emphasized that to lead a moral life and not succumb
to immediate pleasures and gratification, one must
have a moral vision. He identified four cardinal virtues:

(1) wisdom, (2) courage, (3) self-control, and (4)
justice.

Aristotle’s (350 BC) Nicomachean principles also
contribute to virtue ethics. According to this
philosopher, virtues are connected to will and motive
because the intention is what determines if one is or is
not acting virtuously. Ethical considerations, according
to his eudaemonistic principles, address the question,
“What is it to be an excellent person?” For Aristotle,
this ultimately means acting in a temperate manner
according to a rational mean between extreme
possibilities.

Virtue ethics has experienced a recent resurgence in
popularity (Ascension Health, 2007). Two of the most
influential moral and medical authors, Pellegrino and
Thomasma (1993), have maintained that virtue theory
should be related to other theories within a
comprehensive philosophy of the health professions.
They argue that moral events are composed of four
elements (the agent, the act, the circumstances, and
the consequences), and state that a variety of theories
must be interrelated to account for different facets of
moral judgment.

Care ethics is responsiveness to the needs of others
that dictates providing care, preventing harm, and
maintaining relationships. This viewpoint has been in
existence for some time. Engster (2004) stated that

“Carol Gilligan’s In a Different Voice (1982) established
care ethics as a major new perspective in
contemporary moral and political discourse” (p. 113).
The relationship between care and virtue is complex,
however. Benjamin and Curtis (1992) base their
framework on care ethics; they propose that “critical
reflection and inquiry in ethics involves the complex
interplay of a variety of human faculties, ranging from
empathy and moral imagination on the one hand to
analytic precision and careful reasoning on the other”
(p. 12). Care ethicists are less stringently guided by
rules, but rather focus on the needs of others and the
individual’s responsibility to meet those needs. As
opposed to the aforementioned theories that are
centered on the individual’s rights, an ethic of care
emphasizes the personal part of an interdependent
relationship that affects how decisions are made. In
this theory, the specific situation and context in which
the person is embedded become a part of the decision-
making process.

The consensus-based approach to bioethics was
proposed by Martin (1999), who claims that American
bioethics harbors a variety of ethical methods that
emphasize different ethical factors, including principles,
circumstances, character, interpersonal needs, and
personal meaning. Each method reflects an important
aspect of ethical experience, adds to the others, and
enriches the ethical imagination. Thus working with
these methods provides the challenge and the

opportunity necessary for the perceptive and shrewd
bioethicist to transform them into something new with
value through the process of building ethical
consensus. Diverse ethical insights can be integrated
to support a particular bioethical decision, and that
decision can be understood as a new, ethical whole.

Applying Ethics to Informatics
With the Knowledge Age has come global closeness,
meaning the ability to reach around the globe
instantaneously through technology. Language barriers
are being broken through technologically based
translators that can enhance interaction and exchange
of data and information. Informatics practitioners are
bridging continents, and international panels,
committees, and organizations are beginning to
establish standards and rules for the implementation of
informatics. This international perspective must be
taken into consideration when informatics dilemmas
are examined from an ethical standpoint; it promises to
influence the development of ethical approaches that
begin to accept that healthcare practitioners are
working within international networks and must
recognize, respect, and regard the diverse political,
social, and human factors within informatics ethics.

The various ethical approaches can be used to help
healthcare professionals make ethical decisions in all
areas of practice. The focus of this text is on

informatics. Informatics theory and practice have
continued to grow at a rapid rate and are infiltrating
every area of professional life. New applications and
ways of performing skills are being developed daily.
Therefore, education in informatics ethics is extremely
important.

Typically, situations are analyzed using past
experience and in collaboration with others. Each
situation warrants its own deliberation and unique
approach, because each individual patient seeking or
receiving care has his or her own preferences, quality
of life, and healthcare needs in a situational milieu
framed by financial, provider, setting, institutional, and
social context issues. Clinicians must take into
consideration all of these factors when making ethical
decisions.

The use of expert systems, decision support tools,
evidence-based practice, and artificial intelligence in
the care of patients creates challenges in terms of who
should use these tools, how they are implemented, and
how they are tempered with clinical judgment. All
clinical situations are not the same, and even though
the result of interacting with these systems and tools is
enhanced information and knowledge, the clinician
must weigh this information in light of each patient’s
unique clinical circumstances, including that
individual’s beliefs and wishes. Patients are demanding
access to quality care and the information necessary to

control their lives. Clinicians need to analyze and
synthesize the parameters of each distinctive situation
using a specific decision-making framework that helps
them make the best decisions. Getting it right the first
time has a tremendous impact on expected patient
outcomes. The focus should remain on patient
outcomes while the informatics tools available are
ethically incorporated.

Facing ethical dilemmas on a daily basis and struggling
with unique client situations may cause many clinicians
to question their own actions and the actions of their
colleagues and patients. One must realize that
colleagues and patients may reach very different
decisions, but that does not mean anyone is wrong.
Instead, all parties reach their ethical decision based
on their own review of the situational facts and
understanding of ethics. As one deals with diversity
among patients, colleagues, and administrators, one
must constantly strive to use ethical imagination to
reach ethically competent decisions.

Balancing the needs of society, his or her employer,
and patients could cause the clinician to face ethical
challenges on an everyday basis. Society expects
judicious use of finite healthcare resources. Employers
have their own policies, standards, and practices that
can sometimes inhibit the practice of the clinician. Each
patient is unique and has life experiences that affect
his or her healthcare perspective, choices, motivation,

and adherence. Combine all of these factors with the
challenges posed by informatics, and it is clear that the
evolving healthcare arena calls for an informatics-
competent, politically active, consumer-oriented,
business-savvy, ethical clinician to rule this ever-
changing landscape known as health care.

The goal of any ethical system should be that a
rational, justifiable decision is reached. Ethics is always
there to help the practitioner decide what is right.
Indeed, the measure of an adequate ethical system,
theory, or approach is, in part, its ability to be useful in
novel contexts. A comprehensive, robust theory of
ethics should be up to the task of addressing a broad
variety of new applications and challenges at the
intersection of informatics and health care.

The information concerning an ethical dilemma must
be viewed in the context of the dilemma to be useful.
Bioinformatics could gather, manipulate, classify,
analyze, synthesize, retrieve, and maintain databases
related to ethical cases, the effective reasoning applied
to various ethical dilemmas, and the resulting ethical
decisions. This input would certainly be potent—but the
resolution of dilemmas cannot be achieved simply by
examining relevant cases from a database. Instead,
clinicians must assess each situational context and the
patient’s specific situation and needs and make their
ethical decisions based on all of the information they
have at hand.

Ethics is exciting, and competent clinicians need to
know about ethical dilemmas and solutions in their
professions. Ethicists have often been thought of as
experts in the arbitrary, ambiguous, and ungrounded
judgments of other people. They know that they make
the best decisions they can based on the situation and
stakeholders at hand. Just as clinicians try to make the
best healthcare decisions with and for their patients,
ethically driven practitioners must do the same. Each
healthcare provider must critically think through the
situation to arrive at the best decision.

To make ethical decisions about informatics
technologies and patients’ intimate healthcare data and
information, the healthcare provider must be competent
in informatics. To the extent that information technology
is reshaping healthcare practices or promises to
improve patient care, healthcare professionals must be
trained and competent in the use of these tools. This
competency needs to be evaluated through
instruments developed by professional groups or
societies; such assessment will help with consistency
and quality. For the healthcare professional to be an
effective patient advocate, he or she must understand
how information technology affects the patient and the
subsequent delivery of care. Information science and
its effects on health care are both interesting and
important. It follows that information technology and its

ethical, social, and legal implications should be
incorporated into all levels of professional education.

The need for confidentiality was perhaps first
articulated by Hippocrates; thus if anything is different
in today’s environment, it is simply the ways in which
confidentiality can be violated. Perhaps the use of
computers for clinical decision support and data mining
in research will raise new ethical issues. Ethical
dilemmas associated with the integration of informatics
must be examined to provide an ethical framework that
considers all of the stakeholders. Patients’ rights must
be protected in the face of a healthcare provider’s duty
to his or her employer and society at large when
initiating care and assigning finite healthcare
resources. An ethical framework is necessary to help
guide healthcare providers in reference to the ethical
treatment of electronic data and information during all
stages of collection, storage, manipulation, and
dissemination. These new approaches and means
come with their own ethical dilemmas. Often they are
dilemmas not yet faced owing to the cutting-edge
nature of these technologies.

Just as processes and models are used to diagnose
and treat patients in practice, so a model in the
analysis and synthesis of ethical dilemmas or cases
can also be applied. An ethical model for ethical
decision making (Box 5-1) facilitates the ability to
analyze the dilemma and synthesize the information

into a plan of action (McGonigle, 2000). The model
presented here is based on the letters in the word
ethical. Each letter guides and prompts the healthcare
provider to think critically (think and rethink) through
the situation presented. The model is a tool because, in
the final analysis, it allows the nurse objectively to
ascertain the essence of the dilemma and develop a
plan of action.

BOX 5-1 ETHICAL MODEL FOR

ETHICAL DECISION MAKING

Examine the ethical dilemma (conflicting
values exist).
Thoroughly comprehend the possible
alternatives available.
Hypothesize ethical arguments.
Investigate, compare, and evaluate the
arguments for each alternative.
Choose the alternative you would
recommend.
Act on your chosen alternative.
Look at the ethical dilemma and examine the
outcomes while reflecting on the ethical
decision.

APPLYING THE ETHICAL
MODEL

Examine the ethical dilemma:

Use your problem-solving, decision-
making, and critical-thinking skills.

What is the dilemma you are analyzing?
Collect as much information about the
dilemma as you can, making sure to
gather the relevant facts that clearly
identify the dilemma. You should be able
to describe the dilemma you are
analyzing in detail.

Ascertain exactly what must be decided.

Who should be involved in the decision-
making process for this specific case?

Who are the interested players or
stakeholders?

Reflect on the viewpoints of these key
players and their value systems.

What do you think each of these
stakeholders would like you to decide as
a plan of action for this dilemma?

How can you generate the greatest
good?

Thoroughly comprehend the possible
alternatives available:

Use your problem-solving, decision-

making, and critical-thinking skills.

Create a list of the possible alternatives.
Be creative when developing your
alternatives. Be open minded; there is
more than one way to reach a goal.
Compel yourself to discern at least three
alternatives.

Clarify the alternatives available and
predict the associated consequences—
good and bad—of each potential
alternative or intervention.

For each alternative, ask the following
questions:

– Do any of the principles or rules,
such as legal, professional, or
organizational, automatically nullify
this alternative?

– If this alternative is chosen, what do
you predict as the best-case and
worst-case scenarios?

– Do the best-case outcomes
outweigh the worst-case outcomes?

– Could you live with the worst-case
scenario?

– Will anyone be harmed? If so, how
will they be harmed?

– Does the benefit obtained from this
alternative overcome the risk of
potential harm that it could cause to
anyone?

Hypothesize ethical arguments:

Use your problem-solving, decision-
making, and critical-thinking skills.

Determine which of the five approaches
apply to this dilemma.

Identify the moral principles that can be
brought into play to support a conclusion
as to what ought to be done ethically in
this case or similar cases.

Ascertain whether the approaches
generate converging or diverging
conclusions about what ought to be done.

Investigate, compare, and evaluate the
arguments for each alternative:

Use your problem-solving, decision-
making, and critical-thinking skills.

Appraise the relevant facts and
assumptions prudently.

– Is there ambiguous information that
must be evaluated?

– Are there any unjustifiable factual or
illogical assumptions or debatable
conceptual issues that must be
explored?

Rate the ethical reasoning and
arguments for each alternative in terms of
their relative significance.

– 4 = extreme significance

– 3 = major significance

– 2 = significant

– 1 = minor significance

Compare and contrast the alternatives
available with the values of the key
players involved.

Reflect on these alternatives:

– Does each alternative consider all of
the key players?

– Does each alternative take into
account and reflect an interest in the
concerns and welfare of all of the key
players?

– Which alternative will produce the
greatest good or the least amount of
harm for the greatest number of
people?

Refer to your professional codes of
ethical conduct. Do they support your
reasoning?

Choose the alternative you would
recommend:

Use your problem-solving, decision-
making, and critical-thinking skills.

Make a decision about the best
alternative available.

– Remember the Golden Rule: Does
your decision treat others as you
would want to be treated?

– Does your decision take into account
and reflect an interest in the concerns
and welfare of all of the key players?

– Does your decision maximize the
benefit and minimize the risk for
everyone involved?

Become your own critic; challenge your
decision as you think others might. Use
the ethical arguments you predict they
would use and defend your decision.

– Would you be secure enough in your
ethical decision-making process to

see it aired on national television or
sent out globally over the Internet?

– Are you secure enough with this
ethical decision that you could have
allowed your loved ones to observe
your decision-making process, your
decision, and its outcomes?

Act on your chosen alternative:

Use your problem-solving, decision-
making, and critical-thinking skills.

Formulate an implementation plan
delineating the execution of the decision.

– This plan should be designed to
maximize the benefits and minimize
the risks.

– This plan must take into account all
of the resources necessary for
implementation, including personnel
and money.

Implement the plan.

Look at the ethical dilemma and examine
the outcomes while reflecting on your
ethical decision:

Use your problem-solving, decision-
making, and critical-thinking skills.

Monitor the implementation plan and its
outcomes. It is extremely important to
reflect on specific case decisions and
evaluate their outcomes to develop your
ethical decision-making ability.

If new information becomes available, the
plan must be reevaluated.

Monitor and revise the plan as necessary.

The ethical model for ethical decision making was developed by

Dr. Dee McGonigle and is the property of Educational

Advancement Associates (EAA). The permission for its use in

this text has been granted by Mr. Craig R. Goshow, Vice

President, EAA.

Case Analysis Demonstration
The following case study is intended to help readers
think through how to apply the ethical model. Review
the model and then read through the case. Try to apply
the model to this case or follow along as the model is
implemented. Readers are challenged to determine
their decision in this case and then compare and
contrast their response with the decision the authors
reached.

Allison is a charge nurse on a busy
medical–surgical unit. She is expecting

the clinical instructor from the local
university at 2:00 pm to review and
discuss potential patient assignments for
the nursing students scheduled for the
following day. Just as the university
professor arrives, one of the patients on
the unit develops a crisis requiring
Allison’s attention. To expedite the
student nurse assignments for the
following day, Allison gives her electronic
medical record access password to the
instructor.

Examine the Ethical Dilemma
Allison made a commitment to meet with the university
instructor to develop student assignments at 2:00 pm.
The patient emergency that developed prevented
Allison from living up to that commitment. Allison had
an obligation to provide patient care during the
emergency and a competing obligation to the
professor. She solved the dilemma of competing
obligations by providing her electronic medical record
access password to the university professor.

By sharing her password, Allison most likely violated
hospital policy related to the security of healthcare
information. She may also have violated the American
Nurses Association code of ethics, which states that
nurses must judiciously protect information of a

confidential nature. Because the university professor
was also a nurse and had a legitimate interest in the
protected healthcare information, there might not be a
code of ethics violation.

Thoroughly Comprehend the Possible
Alternatives Available
The possible alternatives available include the
following: (1) Allison could have asked the professor to
wait until the patient crisis was resolved; (2) Allison
could have delegated another staff member to assist
the university professor; or (3) Allison could have
logged on to the system for the professor.

Hypothesize Ethical Arguments
The utilitarian approach applies to this situation. An
ethical action is one that provides the greatest good for
the greatest number; the underlying principles in this
perspective are beneficence and nonmaleficence. The
rights to be considered are as follows: right of the
individual to choose for himself or herself (autonomy);
right to truth (veracity); right of privacy (the ethical right
to privacy avoids conflict and, like all rights, promotes
harmony); right not to be injured; and right to what has
been promised (fidelity).

Does the action respect the moral rights of everyone?
The principles to consider are autonomy, veracity, and
fidelity.

As for the fairness or justice, how fair is an action?
Does it treat everyone in the same way, or does it show
favoritism and discrimination? The principles to
consider are justice and distributive justice.

Thinking about the common good assumes one’s own
good is inextricably linked to good of the community;
community members are bound by pursuit of common
values and goals and ensure that the social policies,
social systems, institutions, and environments on which
one depends are beneficial to all. Examples of such
outcomes are affordable health care, effective public
safety, a just legal system, and an unpolluted
environment. The principle of distributive justice is
considered.

Virtue assumes that one should strive toward certain
ideals that provide for the full development of humanity.
Virtues are attitudes or character traits that enable one
to be and to act in ways that develop the highest
potential; examples include honesty, courage,
compassion, generosity, fidelity, integrity, fairness, self-
control, and prudence. Like habits, virtues become a
characteristic of the person. The virtuous person is the
ethical person. Ask yourself, what kind of person
should I be? What will promote the development of

character within myself and my community? The
principles considered are fidelity, veracity, beneficence,
nonmaleficence, justice, and distributive justice.

In this case, there is a clear violation of an institutional
policy designed to protect the privacy and
confidentiality of medical records. However, the
professor had a legitimate interest in the information
and a legitimate right to the information. Allison trusted
that the professor would not use the system password
to obtain information outside the scope of the legitimate
interest. However, Allison cannot be sure that the
professor would not access inappropriate information.
Further, Allison is responsible for how her access to the
electronic system is used. Balancing the rights of
everyone—the professor’s right to the information, the
patients’ rights to expect that their information is
safeguarded, and the right of the patient in crisis to
expect the best possible care—is important and is the
crux of the dilemma. Does the patient care obligation
outweigh the obligation to the professor? Yes, probably.
Allison did the right thing by caring for the patient in
crisis. By giving out her system access password,
Allison also compromised the rights of the other
patients on the unit to expect that their confidentiality
and privacy would be safeguarded.

Virtue ethics suggests that individuals use power to
bring about human benefit. One must consider the
needs of others and the responsibility to meet those

needs. Allison must simultaneously provide care,
prevent harm, and maintain professional relationships.

Allison may want to effect a long-term change in
hospital policy for the common good. It is reasonable to
assume that this event was not an isolated incident and
that the problem may recur in the future. Can the
institutional policy be amended to provide professors
with access to the medical records system? As
suggested in the HIPAA administrative guidelines, the
professor could receive the same staff training
regarding appropriate and inappropriate use of access
and sign the agreement to safeguard the records. If the
institution has tracking software, the professor’s access
could be monitored to watch for inappropriate use.

Identify the moral principles that can be brought into
play to support a conclusion as to what ought to be
done ethically in this case or similar cases. The
International Council of Nurses (2006) code of ethics
states that “The nurse holds in confidence personal
information and uses judgment in sharing this
information” (p. 4). The code also states, “The nurse
uses judgment in relation to individual competence
when accepting and delegating responsibilities” (p. 5).
Both of these statements apply to the current situation.

Ascertain whether the approaches generate
converging or diverging conclusions about what ought
to be done. From the analysis, it is clear that the best

immediate solution is to delegate assisting the
professor with assignments to another nurse on the
unit.

Investigate, Compare, and Evaluate
the Arguments for Each Alternative
Review and think through the items listed in Table 5-1.

Table 5-1 Detailed Analysis of Alternative Actions

Alternative Good
Consequences

Bad
Consequences

Do Any
Rules
Nullify

Expected
Outcome

1. Wait

until

crisis

was

resolved

No policy

violation

Patient rights

safeguarded

Not the best

use of the

professor’s time

No Best: Crisis

will require a

short time

Worst: Crisis

may take a

long time

2.

Delegate

to

another

staff

member

No policy

violated

Other staff may

be equally busy

or might not be

as familiar with

all patients

No Best:

Assignments

will be

completed

Worst: May

not have

benefit of

expert

advice

3. Log on

to the

system

for the

professor

Professor can

begin making

assignments

May still be a

violation of

policy regarding

system access

Rules

regarding

access to

medical

record

Best:

Assignments

can be

completed

Worst:

Abuse of

access to

information

Choose the Alternative You Would
Recommend
The best immediate solution is to delegate another
staff member to assist the professor. The best long-
term solution is to change the hospital policy to include
access for professors, as described previously.

Act on Your Chosen Alternative
Allison should delegate another staff member to assist
the professor in making assignments.

Look at the Ethical Dilemma and
Examine the Outcomes While
Reflecting on the Ethical Decision
As already indicated in the alternative analyses,
delegation may not be an ideal solution because the

staff nurse who is assigned to assist the professor may
not possess the same extensive information about all
of the patients as the charge nurse. It is, however, the
best immediate solution to the dilemma and is certainly
safer than compromising the integrity of the hospital’s
computer system. As noted previously, Allison may
want to pursue a long-term solution to a potentially
recurring problem by helping the professor gain
legitimate access to the computer system with the
professor’s own password. The system administrator
would then have the ability to track who used the
system and which types of information were accessed
during use.

This case analysis demonstration provides the authors’
perspective on this case and the ethical decision made.
If your decision did not match this perspective, what
was the basis for the difference of opinion? If you
worked through the model, you might have reached a
different decision based on your individual background
and perspective. This does not make the decision right
or wrong. A decision should reflect the best decision
one can make given review, reflection, and critical
thinking about this specific situation.

Six additional cases are provided in the online learner’s
manual for review. Apply the model to each case study,
and discuss these cases with colleagues or
classmates.

New Frontiers in Ethical Issues
The expanding use of new information technologies in
health care will bring about new and challenging ethical
issues. Consider that patients and healthcare providers
no longer have to be in the same place for a quality
interaction. How, then, does one deal with licensing
issues if the electronic consultation takes place across
a state line? Derse and Miller (2008) describe a
second-opinion medical consultation on the Internet
where the information was provided to the referring
physician and not to the patient, thus avoiding the
licensing issue. In essence, provider-to-provider
consultation does not constitute practicing in a state in
which you are not licensed. As new technologies for
healthcare delivery are developed, new ethical
challenges may arise. It is important for all healthcare
providers to be aware of the code of ethics for their
specific practices, and to understand the laws
governing their practice and private health information.