Far Eastern University

INSTITUTE OF NURSING
N. Reyes St., Sampaloc Manila 1008

Nursing Informatics
Concept II - Concepts, Principles and Theories in Nursing Informatics

I. MODULE INTRODUCTION

Nursing ―in acute-care settings has grown so complex that it is no longer possible to standardize,
routinize, and delegate much of what the nurse does. Increased acuity levels of patients’ decreased
length of hospitalization, and the proliferation of health care technology and specialization had
increased the need for highly experienced nurses. The complexity and responsibility of nursing
practice today requires long-term and ongoing career development. This, in turn, requires an
understanding of the differences between the experienced nurse and‖ the novice.

II. PURPOSE AND OBJECTIVES

Objectives:
At the end of this module, you will be able to:
1. Describe the theoretical models in nursing informatics
2. Explain the distinguishing features
3. Describe the levels of Novice to Expert theory

III. THEORIES

The Novice to Expert Theory

The Novice to Expert Theory, a construct theory first proposed by Hubert and
Stuart Dreyfus (1980) as the Dreyfus Model of Skill Acquisition, and later applied
and modified to nursing by Patricia Benner (1984) provides a very useful and
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important theory that clearly applies to nursing informatics.

Source: cjni.net

Within the field of nursing informatics, this theory can be applied to:

1. the development of nursing informatics skills, competencies, knowledge and

expertise in nursing informatics specialists;
2. the development of technological system competencies in practicing nurses
working in an institution;
3. the education of nursing students, from first year to graduation and;
4. the transition from graduate nurse to expert nurse.

The currently accepted five levels of development within the Novice to Expert
theoretical model are illustrated in the image above, as presented by Benner (1984).
They start from the bottom rung at the Novice level and move upward through
Advanced Beginner, Competent, Proficient, and Expert levels. Dreyfus and Dreyfus
(1980) initially proposed the stages of Novice, Competent, Proficient, Expertise and
Mastery. In both configurations, each level builds on the level before it as the
learner advances from a neophyte level then gains knowledge, skills, perceptions,
intuition, wisdom and most important of all, experience in their given field of
practice.
Distinguishing features
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Both Dreyfus and Dreyfus and Benner estimated that it takes approximately five
years to move through the five stages from novice to expert but also elaborated that
not all novices become experts. Some people get ‗stuck‘ at the competent or
proficient stages. Two personal characteristics that distinguish the successful
evolution to the expert level seem to be
1. deliberate practice and
2. the willingness to take risks, to go beyond the ‗norm‘.

Deliberate practice is a trait shown by people who use a personal, goal-oriented

approach to skill and knowledge development – they devote themselves to engage
in progressively higher, and ultimately expert performance. This requires years of
sustained effort to continually improve the quality of their practice and performance
within the skill – in this case, in nursing informatics skills. They feel personal
satisfaction in confronting challenges to achieve a high standard of excellence
within their field. They are not content to acquire merely functional and
rudimentary skill levels – they want to shine and join the ranks of the experts in the
field.
Taking Risks – This continuous climb to the expert level is not without perceived
‗risks‘ – it requires people to move beyond the status quo of mere competence
through the levels of Proficiency, then Expertise. This is a quality often seen in
Super Users and Champions within the nursing informatics arena. To move to this
level, many different perspectives must be digested, and the zone of comfort can
become threatening. Many people do not like to stand out from the rest, so do not
risk the possibility of being perceived as different or peculiar – nor do they want to
be regarded as thinking that they excel above their peers. Yet, the true expert
must take this risk and continue to move up the ladder of skill and knowledge
acquisition despite potential conflict within the nursing workplace.
Some common themes are evident as a person successfully progresses through the
novice to expert levels:
1. As progression occurs, the person tends to move away from relying on rules

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 and explicit knowledge to learning to trust and follow their intuition and
pattern matching.
2. Better cognitive filtering occurs, where problems are no longer a huge
confusing collection of data but instead become a complete and unique
whole where some bits are much more relevant than others.
3. The person also moves from being a detached observer of a problem to an
involved part of the system itself, accepting responsibility for results, not
just for carrying out tasks.
3.0 Novice to Expert level
The level of skill acquired have some distinguishing behavior and features peculiar
to each of the levels in Novice to Expert theory (Frisoli, 2007). These are
enumerated below:
Novice

A novice does not know anything about the subject he/she is approaching and has
to memorize its context-free features. The novice is then given rules for
determining an action on the basis of these features. To improve, the novice needs
monitoring, either by self-observation or instructional feedback. For example, a
nurse learning to use a new hospital information system needs explicit instruction
and ‗rules‘ to learn to use the computer interface and manipulate the software.
Advanced Beginner
An advanced beginner is still dependent on rules, but as s/he gains more experience
with real-life situations, s/he begins to notice additional aspects that can be applied
to related conditions.

Competent
At this stage, the competent person grasps all the relevant rules and facts of the
field and is, for the first time, able to bring his/her own judgment to each case. This
is the stage of learning that is often characterized by the term ―problem-solving.‖
A competent level nurse would be able to use a hospital information system with

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ease and know-how to solve technical difficulties or interpret conflicting data.
Proficient
The fourth stage is called fluency and is characterized by the progress of the learner
from the step-by-step analysis and solving of the situation to the holistic perception
of the entirety of the situation. The proficient hospital information system learner
would know how to interpret data from all departmental information and provide
guidance to other disciplinary members as needed.
Expert
An expert‘s repertoire of experienced situations is so vast that normally each
specific situation immediately dictates an intuitively appropriate action. After a
great deal of experience actually using a system in everyday situations, the expert
nurse discovers that without his consciously using any rules, situations simply elicit
from him or her appropriate responses. The proficient performer, immersed in the
world of his skillful activity, sees what needs to be done, and decides how to do it.
The expert not only knows what needs to be achieved, thanks to the well-refined
ability to exercise situational discrimination, s/he knows how to achieve his or her
goal.

The DIKW Theory

When raw data is collected, it gets mixed up and the view seems jumbled. The DIKW Model
by Fricke (2018) on Russell Ackoff (1989) describes how the data can be processed and
transformed into information, knowledge, and wisdom.
The DIKW Hierarchy comprises of the following:
“D” = Data
“I” = Information
“K” = Knowledge
“W” = Wisdom
The DIKW model of transforming data into wisdom can be viewed from two different
concepts, which are contextual and understanding.
From the contextual concept, one moves from a phase of gathering data parts (data), the

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connection of raw data parts (information), formation of whole meaningful contents
(knowledge) and conceptualizing and joining those whole meaningful contents (wisdom).
From the understanding concept, the DIKW Pyramid can be viewed as a process starting with
researching & absorbing, doing, interacting, and reflecting.
The DIKW hierarchy can also be represented in terms of time. For instance, the data,
information, and knowledge levels can be seen as the past while the final step - wisdom -
represents the future.
Please refer to the following diagram to understand the representation:

The "Data" of DIKW Hierarchy:

The first step in this DIKW model is Data. Collection of raw data is the main requirement for
coming up with a meaningful result in the end. Any measurements, logging, tracking, records
and many others are all considered as data. Since the raw data is collected in bulk, it includes
various things both useful and not so useful contents.
These are completely raw data and do not provide any meaningful result that can be used by
the Information Technology (IT) Service provider. Therefore the data doesn't answer any
question nor draw any conclusion.
To understand how the Data is transformed into utilizable results using the DIKW Pyramid
model, we will discuss each of the subsequent steps of the of DIKW hierarchy (i.e. -
information, knowledge, and wisdom) using sample scenarios.
For Example, Let’s assume the scenario is - 300 Users visits FEU on Canvas daily to take
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online lessons. This is the raw data we have got from statistics.
The "Information" of DIKW Pyramid:
Information can be termed as the data that has been given a meaning by defining relational
connections. Here, the word "meaning" represents processed and understandable data that may
or may not be a useful piece of content from the organization perspective.
In information processing system, a relational database creates information from the data
stored within it.
The information hierarchy stage of DIKW Pyramid reveals the relationships in the data, and
then the analysis is carried out to find the answer to Who, What, When and Where questions.
Now let come to the above example, the data “300 users visit FEU on Canvas per day”, which
is quite a generic number to get any insight. Now, to do the capacity planning and availability
planning, we must process it through information stage of DIKW Hierarchy.
Now we can get answers like - 150 Users visit Nursing Pharmacology, 145 User visits Nursing
Research, 5 Users just visits the dashboards. Out of them, 60% is in the age group of 18-22
years, 20% in age group of 22-26 Years. Also, we get 70% of our visitors between 9 AM to 11
PM.
In the given scenario above, the generic data now become an information answering the
questions of Who, What, When, and Where. This is the output we can get from information
stage.

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The "Knowledge" of DIKW Model:
Knowledge is the third level of DIKW Model. Knowledge means the appropriate collection of
information that can make it be useful.
Knowledge stage of DIKW hierarchy is a deterministic process. When someone "memorizes"
information due to its usefulness, then it can be said that they have accumulated knowledge.
Every piece of knowledge itself has useful meanings, but it can't generate further knowledge
on its own.
In information management system, most of the applications you use, such as modelling,
simulation etc, exercise some sort of stored knowledge.
The knowledge step tries to find the answer to the "How" question. Specific measures are
pointed out, and the information derived in the previous step is used to answer this question.
With respect to our scenario, we must find the answer that “How do student nurses between
the age group of 18-22 years use our modular approach?”

The “Wisdom” of DIKW Hierarchy:

The Wisdom is the fourth and the last step of the DIKW Hierarchy. It is a process to get the
final result by calculating through extrapolation of knowledge. It considers the output from all
the previous levels of DIKW Model and processes them through special types of human
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programming (such as the moral, ethical codes, etc.).
Therefore, Wisdom can be thought as the process by which you can take a decision between
the right and wrong, good and bad, or any improvement decisions.
Alternatively, we can say that in wisdom stage, the knowledge found in the previous stage is
applied and implemented in practical life.
Wisdom is the topmost level in the DIKW pyramid and answers the questions related to
"Why".
In case of our example scenario, one example of wisdom gained might be that due to 70 % of
the student nurses visit our modules to get help with their lessons and technology needs.

Analyzing Organizational Issues Using the DIKW Hierarchy:

Data: A way to identify the raw external inputs such as the facts and figures that are yet to be
interpreted.
Information: Analyze the raw data to determine the organizational needs. An important aspect
of information management is that apart from answering questions it can also help to find
other solutions in organizational contexts.
Knowledge: Determines how something is remembered by an individual or how information is
applied by them.
Wisdom: Uncover why the derived knowledge is applied by individuals in a specific way. i.e. -
finding the reason behind any decision-making.

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The Usage and Limitations of DIKW Model:
Same as all other models, DIKW Model also has its own limits. You may have noticed that the
DIKW Hierarchy is quite linear and follows a logical sequence of steps to add more meaning
to data in every step forward. But the reality is often quite different than that. The Knowledge
stage, for example, is practically more than just a next stage of information.
One of the principal critiques of this DIKW Pyramid is that it’s a hierarchical process and
misses several important aspects of knowledge. In today's world, where we use various ways
to capture and process more and more unstructured data, sometimes forces us to bypasses few
steps of DIKW.
Though the previous statement is quite true, however, the result still stays the same, such as
what we do with the data warehouse and transforming data through big data analytics into
decisions and actions (Wisdom).

B. Computer System
1. Computer Hardware
Hardware refers to the physical parts of the computer. It allows the user to enter data into the

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computer, performs the actions of the computer’s processing, and produces the computer
output. (Kozier, 2016) The size, shape, and type varies depending on the purpose of the
computer. The essential components of computer hardware are the central processing units
(CPUs) and the different types of input and output devices that may also vary from one or
more types.
2. Computer Hardware Systems
The CPU is in the box that comprises the computer hardware necessary to process and store
data. The power supply, disk drives, chips, and connections for all other computer hardware
(also known as peripherals) are also located with the CPU. The performance of the CPU or
the determinant of how fast the CPU’s performance is known by three components:
3. CPU processor cores and clockspeed, which is typically measures in gigahertz
4. The amount of random-access memory (RAM)
5. The speed of data location or transfer rate of the disk drives.

Processor cores and clock speed are very different functions, but they’re working toward the
same goal. Many computer experts talk about which you should give more empahsis to when
purchasing or selecting a computer - but they depend on each other equally to help your
computer function at its best. Processor cores are individual processing units within the
computer’s central processing unit (CPU). The processor core receives instructions from a
single computing task, working with the clock speed to quickly process this information and
temporarily store it in the Random Access Memory (RAM). Permanent information is saved to
your hard drive when you request it. Most computers now have multiple processor cores that
enable your computer to finish multiple tasks at once. Having the ability to run numerous
programs and request multiple tasks like editing a document and at the same time streaming a
video, as well as opening a new program, is made possible with multiple processor core units.

A computer’s processor clock speed determines how quickly the central processing unit (CPU)
can retrieve and interpret instructions. This helps your computer complete more tasks by
getting them done faster. Clock speeds are measured in gigahertz (GHz), with a higher number

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then the higher is the clock speed. Multi-core processors were developed to help CPUs run
faster as it became more difficult to increase clock speed.
Faster clock speeds mean that users can see tasks ordered from the CPU to be completed faster,
making the user’s experience seamless and reducing the time waiting to interface with
applications and programs.
Based on Sirois (2018) on a review for HP Computers, the reasonable fast CPU based on
average usage is between 3.5 to 4.0 GHz.

3. Open Source and Free Software

Softwares are the instructions being given to the hardware to perform certain tasks. They are
classified based on availability and shareability as to free and open-source softwares and
propriety or closed softwares.

Free and open-source software (FOSS) allows users and programmers to edit, modify or reuse
the software's source code. This gives developers the opportunity to improve program
functionality by modifying it.

The term “free” indicates that the software does not have constraints on copyrights. The term
“open source” indicates the software is in its project form, enabling easy software development
from expert developers collaborating worldwide without any need for reverse engineering.

Free and open-source software may also be referred to as free/libre open-source software
(FLOSS) or free/open-source software (F/OSS).

The basic and old classifications of softwares include: System and Application Softwares.

System Softwares helps the user, hardware , and application software to interact and function
together. These types of computer software allow an environment or platform for other
software and applications to work in. This is why system software is essential in managing the
whole computer system.

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When you first power up your computer, it is the system software that is initially loaded into
memory. Unlike application software, the System software is not used by end-users like you. It
only runs in the background of your device, at the most basic level while you use other
application software. This is why system software is also called “low-level software”.

Application Softwares or most popularly known as “apps” are what users regualrly engage
with the most of the time. These types of computer software are productive end-user programs
that help you perform tasks. It can range from word processing to image editing, voice
communication or conferences, internet browsers, and many others.

With the advancement of technology, the software classification continues to change but the
usability remains to be the main basis for its classification.

4. Data Assessment
Data quality assessment (DQA) is the process of scientifically and statistically evaluating data
in order to determine whether they meet the quality required for projects or business processes
and are of the right type and quantity to be able to actually support their intended use. It can be
considered a set of guidelines and techniques that are used to describe data, given an
application context, and to apply processes to assess and improve the quality of data.
Data quality assessment (DQA) exposes issues with technical and business data that allow the
organization to properly plan for data cleansing and enrichment strategies. This is usually done
to maintain the integrity of systems, quality assurance standards and compliance concerns.
Generally, technical quality issues such as inconsistent structure and standard issues, missing
data or missing default data, and errors in the data fields are easy to spot and correct, but more
complex issues should be approached with more defined processes.
DQA is usually performed to fix subjective issues related to business processes, such as the
generation of accurate reports, and to ensure that data-driven and data-dependent processes are
working as expected.
DQA processes are aligned with best practices and a set of prerequisites as well as with the five
dimensions of data quality:

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 • Accessibility
• Accuracy and reliability
• Serviceability
• Methodological soundness
• Assurances of integrity

5. Personal, Professional, and Educational Informatics

Personal Informatics
Information services, often accessible via a mobile device, that search, sort, mine, correlate or
otherwise filter information for a person based on their preferences, transaction logs, location,
social networks and other personal data.
Professional Informatics
Health informatics professionals use their knowledge of healthcare, information systems,
databases and information technology security to gather, store, interpret and manage the
massive amount of data generated when care is provided to patients. ... Developing data-driven
solutions to improve patient health.

Educational Informatics
Education informatics is an emerging sub-discipline of education and informatics that
"incorporate[s] new technologies and learning strategies to enhance the capture, organization,
and utilization of information within the field of education."
While this sub-discipline typically covers K-12 and higher education, it is easily expanded to
business- and enterprise-level education.

Conclusion
The novice to expert theory can be used as a predetermined clinical guideline for
conducting all practices associated with nursing career. The model/theory is highly
important to the practice of nursing for better service and care giving to patients.
5.0 Summary
In this unit, you have learnt
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 1. Novice to Expert theory and areas where it can be applied
2. The distinguishing features of novice to expert theory
3. The five level of the Novice to Expert theory

6.0 Online discussion and assignment

1. Describe the Novice to Expert theory and their distinguishing features?
2. In nursing profession, site some importance of determining the level of expertise of nurses.
3. Enumerate the Novice to Expert levels?
4. Matching type.
Situation: Mrs. P is a married, mother of two 8-month old twins. Mrs. P has been discharged from the hospital
after she underwent reconstructive abdominal surgery last week, due to an umbilical hernia. She is not allowed
to lift any weight above 11 Lbs (5 kg) for 8 weeks after the surgery. Mrs P. is an insulin dependent diabetes and
she injects insulin to her abdomen several times a day.
1. Data - D A. 8-month old babies need to be lifted several times a day
2. Information-A B. Mrs. P may have trouble taking care of her babies now that she is
not able to lift after surgery
3. Knowledge-B C. Mrs. P should be closely monitored to make sure her wound heals
well
4. Wisdom-C D. Mrs. P underwent surgery last week
5. Data-H E. Insulin dependent diabetics often have delayed wound healing
6. Information-E F. Mrs. P is limited in injecting insulin into her abdomen due to post-
surgical pain
7. Knowledge-F G. Mrs. P and her partner should be instructed how to inject insulin
in other places than her abdomen
8. Wisdom-G H. Mrs. P is the mother of baby twins

7.0 References/further reading

American Nurses Association (ANA). (2008). Nursing informatics: Scope and
standards of practice. Silver Spring, MD: Nursebooks.org.
Baker, J. (2012). Nursing informatics. Perioperative Nursing Clinics, 7, 151-160.

Frické M.H. (2018) Data-Information-Knowledge-Wisdom (DIKW) Pyramid,

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Framework, Continuum. In: Schintler L., McNeely C. (eds) Encyclopedia of Big
Data. Springer, Cham

Kaminski, J. (Fall, 2010). Theory applied to informatics – Novice to Expert.

CJNI:
Canadian Journal of Nursing Informatics, 5 (4),
Editorial. http://cjni.net/journal/?p=967
McGonigle D., & Mastrian K (2009). Nursing Informatics and the foundation of
knowledge USA: Delma Publishers.
(PDF) Nursing Information System. Available
from:
https://www.researchgate.net/publication/235744215_Nursing_Information_System
[accessed Jan 17 2020

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