the evolution of data- information-knowledge-wisdom in

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Advances in Nursing ScienceVol. 39, No. 1, pp. E1–E18Copyright c© 2016 Wolters Kluwer Health, Inc. All rights reserved.

The Evolution of Data-Information-Knowledge-Wisdomin Nursing Informatics

Charlene Ronquillo, MSN, RN; Leanne M. Currie, PhD, RN;Paddy Rodney, PhD, RN

The data-information-knowledge-wisdom (DIKW) model has been widely adopted in nursinginformatics. In this article, we examine the evolution of DIKW in nursing informatics whileincorporating critiques from other disciplines. This includes examination of assumptions oflinearity and hierarchy and an exploration of the implicit philosophical grounding of themodel. Two guiding questions are considered: (1) Does DIKW serve clinical informationsystems, nurses, or both? and (2) What level of theory does DIKW occupy? The DIKW modelhas been valuable in advancing the independent field of nursing informatics. We offer that ifthe model is to continue to move forward, its role and functions must be explicitly addressed.Key words: information science, nursing informatics, nursing philosophy, nursing theory

If we cannot name it, we cannot control it, fi-nance it, teach it, research it, or put it into publicpolicy.

Norma Lang (in Clark and Lang)1

M AKING NURSING WORK VISIBLE hasbeen a historical challenge that the pro-

fession continues to contend with. Early re-search sought to distinguish nursing workas distinct from other professions, informedby its own bodies of knowledge. Meanwhile,contemporary challenges include develop-ing quantifiable ways of representing nursingwork, developing methods to capture aspectsof nursing that “can’t be quantified,” identi-fying nursing-sensitive outcomes, and issuesrelated to the move toward digitized health

Author Affiliation: School of Nursing, University ofBritish Columbia, Vancouver, British Columbia,Canada.

The authors have no conflicts of interest to declare.

Correspondence: Charlene Ronquillo, MSN, RN,School of Nursing, University of British Columbia,T201-2211 Wesbrook Mall, Vancouver, BC V6T 2B5,Canada ([email protected]).

DOI: 10.1097/ANS.0000000000000107

systems. Operationalizing ways of makingnursing work visible, valued, and “counted”in health systems, facilitated by the use ofinformation technology has been a founda-tional driving force in the field of nursinginformatics.1

Seminal work by Graves and Corcoran2

was aimed to outline the scope and definethe field of nursing informatics and to delin-eate and define nursing work as related toinformation technology. A foundational con-ceptual approach described by Graves andCorcoran as central to nursing informatics isthe data, information, knowledge, wisdom(DIKW) framework, which continues to playa central role in the field today. By outlin-ing the definitions, roles, and interrelation-ships within DIKW, the framework has un-doubtedly been instrumental in moving andinforming the field toward the goal of makingnursing work visible. Interest in DIKW hasbeen sustained, and its evolution has contin-ued over the decades, illustrated by the var-ious iterations and revisions of the model tomeet the needs of contemporary nursing3-5

and the continued efforts and approaches tobetter understand the framework and exploreits application.6

Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

E1

mailto:[email protected]

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E2 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2016

The aims of this article are (1) to exam-ine the theoretical foundations of the DIKWmodel through deconstruction of some im-plicit claims within the model and (2) to stepback to examine potential reasons why DIKWhas come to be depicted in the way that ithas. To achieve our aims, we have used 2approaches. First, we conducted a literaturereview, focusing in particular on other fieldsof study where DIKW has been taken up. Sec-ond, we examined syntheses of some maincritiques of DIKW, particularly in relation tothe way that DIKW has been taken up in nurs-ing. This second approach led to a philosoph-ical exploration of the implicit assumptionsthat the concepts within DIKW are foundedon and interpretations of the model’s pre-sumed purpose and theoretical application.Our philosophical exploration includes somereflections on the implications for nursing’sobligations to diverse populations and inter-disciplinarity.

DIKW IN NURSING INFORMATICS

Graves and Corcoran’s2 seminal paper,“The Study of Nursing Informatics,” estab-lished nursing informatics as a field of schol-arly inquiry in the late 1980s and early 1990s.6

They describe nursing informatics as “a com-bination of computer science, informationscience and nursing science designed to assistin the management and processing of nursingdata, information and knowledge to supportthe practice of nursing and the delivery ofnursing care.”2(p227) Nursing informatics cap-tures the juncture of these 3 core sciences;the focus on nursing science differentiatesnursing informatics from other specialties,such as biomedical informatics.5 Graves andCorcoran’s article is acknowledged as instru-mental in shifting the discourse in nursinginformatics from being concerned with tech-nology itself to the purpose of technology andconcepts related to information science inthe context of nursing.7 On the foundationsof nursing informatics, Graves and Corcoranexplained:

This framework for nursing informatics relies ona taxonomy and definition of the central conceptsof data, information and knowledge put forwardby Blum (1986), who defines data as discrete enti-ties that are described objectively without interpre-tation, information as data that are interpreted,organized or structured and knowledge as infor-mation that has been synthesized so that inter-relationships are identified and formalized.2 (SeeFigure 1 for Graves and Corcoran’s depiction ofdata-information-knowledge [DIK].)

In the field of nursing informatics, Nelsonand Joos are cited as the first to add the con-cept of wisdom in 1989, described as the“appropriate use of knowledge in managingor solving human problems . . . it [wisdom]is knowing when and how to use knowl-edge to manage a patient need or problem.”8

The American Nurses Association’s Scope andStandards for Nursing Informatics adopted theinclusion of wisdom to the DIK framework in2008, arguing that it “reflects today’s emerg-ing mandate for evidence-based practice anddecision support resources for the knowledgeworker.”9(p855)

The conceptualization of DIK and the ad-dition of wisdom are important develop-ments in the attempts to better articulateand make nursing work visible, particularlyin relation to the digitization of health sys-tems. DIKW has been instrumental in ex-panding the scope of practice in nursinginformatics to be “no longer fully definedby the functionality of a computer and thetypes of applications processed by a com-puter . . . [but is] now defined by the goalsof nursing and nurse-computer interactionsin achieving these goals.”4(p27) Through these

Figure 1. Conceptual framework for the study ofnursing informatics (as proposed by Graves andCorcoran2). Reprinted with permission.


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The Evolution of DIKW in Nursing Informatics E3

developments, DIKW has become a canonicalframework in nursing informatics.

ORIGINS OF DIK AND DIKW

Graves and Corcoran adopted the DIKframework from Blum’s 1986 book, wherehe suggested that medical computing had4 phases: (1) 1955-1965: experimentationand orientation; (2) 1965-1975: data pro-cessing success; (3) 1975-1985: informationprocessing success; and (4) 1985-[1986 andfuture]: knowledge processing success. Hefurther described 3 types of applications:(1) data-oriented applications, such as sys-tems designed for business data, clinical lab-oratory data, patient monitoring, diagnosticsystems, and imaging (eg, computed tomo-graphic scan); (2) information-oriented ap-plications including clinical information sys-tems that can provide administrative support(eg, reduce errors) and medical decision sup-port (eg, alerts and reminders to support clin-ical decision making); and (3) knowledge-oriented applications such as bibliographicdatabases, and artificial intelligence systems(ie, systems that have the ability to apply“smart reasoning”).10 In his book, Blum ac-knowledges that systems at the time had dif-ficulty codifying “the most elementary bodyof knowledge—common sense.” It is un-clear where the model posed by Blum orig-inated. Desrosieres11 suggests that the ori-gins of DIK derives from the 17th-centuryideas of taxonomies of nature that later ma-tured into classification of populations to-ward “the construction and stabilization ofsocial order . . . , the production of a commonlanguage allowing individual acts to be co-ordinated and . . . [for systems to be ableto be] capable of orientation and triggeringaction.” Given the rapidly increasing prolif-eration of complex work related to nurs-ing informatics happening nationally and in-ternationally, we believe that an approachsuch as DIK can provide a common lan-guage and coordination of individuals fromvarious disciplines (eg, nursing, computer sci-

ence, information science, medicine) is mostwelcome.

The addition of “wisdom” to the DIK modelhas largely been attributed to Ackoff’s 1989address to the Society for General Systems. Inthis address, Ackoff12 accentuates the inter-play between knowledge and wisdom, and al-though he does not present a graphical depic-tion of the ideas, he clearly suggests a hierar-chical format wherein the concepts of DIKWbuild one upon the other.

THE EVOLUTION OF DIKW IN NURSINGINFORMATICS

Since it was first introduced in nursing 26years ago, the evolution and refinement ofDIK and then DIKW have been ongoing, withthe most recent changes to the model madein 2013.4 The various revisions of DIKW haveaimed to address the limitations of the originalmodel by providing further details of the re-lationships and interactions between the con-cepts of DIKW. Figures 2-4 show the evolu-tion of visual depiction of the DIKW model.

The relevance of the DIKW framework innursing informatics is illustrated by the on-going adaptation and extension of the frame-work to underpin research studies. For ex-ample, Gee et al13 suggest an extension ofthe DIKW framework by integrating clin-icians and the e-patient into the model.This is framed as the DIKW CollaborativeModel, where the e-patient, or electronicpatient, is one who uses information re-sources on the Internet to self-manage hisor her own health. Gee et al13 posit thatthe crucial interaction between the clini-cian and the e-patient can be supported bythe DIKW framework and suggest that datacould be coproduced by patients and clin-icians. They note that the “e-patient couldeducate the health care team on what datamean in their life context . . . and togetherthey would create plans . . . using collectivewisdom from support groups, social network-ing sites, blogs, databases and research”13

(see Figure 5).


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Figure 2. Nelson DIKW, version 1 (2001), is the original visual depiction of the DIKW theoretical model asreferred to in nursing informatics. DIKW indicates data-information-knowledge-wisdom. Copyright ownershipby Ramona Nelson, Ramona Nelson Consulting. All rights reserved. Reprinted with permission.

Figure 3. Nelson DIKW, version 2 (2008), adds constant flux, suggesting the possibility of bidirectional move-ment across the DIKW continuum. DIKW indicates data-information-knowledge-wisdom. Copyright ownershipby Ramona Nelson, Ramona Nelson Consulting. All rights reserved. Reprinted with permission.


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Figure 4. Nelson DIKW, version 3 (2013), maintainsbidirectional movement with constant flux and isrevised to suggest greater interaction, overlap, andinterrelationships between concepts, as well as thepossibility of moving back and forth between con-stituent concepts. DIKW indicates data-information-knowledge-wisdom. Copyright ownership by RamonaNelson, Ramona Nelson Consulting. All rights re-served. Reprinted with permission.

Looman et al14 used the DIKW frameworkto inform their study of care coordination inthe context of telehealth for families. In theirconceptual model, the DIKW constructs aredepicted as underpinning a model of care co-ordination; data are conceptualized as historicor current and as subjective or objective, and

Figure 5. The DIKW model as depicted by Gee et al.13

DIKW indicates data-information-knowledge-wisdom.Reprinted with permission.

knowledge is conceptualized as tacit or ex-plicit, and these are underpinned by wisdom(see Figure 7).

Most recently, Matney and colleagues15,16

have proposed a theory of Wisdom-in-Action.In this model, the concept of data has beensubsumed into the context of electronichealth records and the concepts of informa-tion, knowledge, and wisdom are clearly de-lineated as interacting with each other (seeMatney15 for visual representation).

CRITICISMS OF THE DIKW MODEL

Although various revisions of DIKW innursing informatics illustrate continued at-tempts at better delineating and understand-ing the model and its application, critiques ofDIKW in other fields have been more explicit,systematic, and nuanced and have sought tochallenge the model. The following sectionsconsider perspectives of DIKW from nurs-ing informatics in light of criticisms of DIKWfrom the fields of information science, knowl-edge management, geography, managementinformation systems, and library informationsciences. The critiques we have synthesizedfrom our literature review focus on the limi-tations of DIKW’s hierarchical structure andepistemological narrowness in understandingthe concepts of DIKW.

LINEARITY AND HIERARCHY IN DIKW

Published critiques of DIKW outside ofnursing focus largely around the uncritical ac-ceptance of DIKW and the implications ofaccepting it at face value, as well as the in-ability to operationalize the model.17-21 As weshow in what follows, these critiques coa-lesce around concerns about the linearity andhierarchy implicit in how the model is takenup.

In the field of information science, DIKWis referred to as the knowledge/informationhierarchy or information/knowledge pyra-mid and is visually represented in a manner


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Figure 6. A side-by-side comparisons of the DIKW models as depicted in nursing informatics (left) and computerscience, management information systems, and library sciences (right) illustrate the common attributes of DIKWvisualizations: consolidation of power, linear and positive growth, and an implicit assignment of value to concepts(ie, "building" toward to the pinnacle of wisdom, which is the most important). DIKW indicates data-information-knowledge-wisdom.

different from that of DIKW in nursing in-formatics (see Figure 6). Data are describedto be most abundant, forming the founda-tional level upon which the remaining con-cepts build on, with the decreasing width ofthe triangle at each level suggesting decreasedabundance.22 Concurrently, movement upthe triangle suggests increasing power tosupport the ability to take appropriateaction.22

In information science, reference to DIKWas a knowledge hierarchy alludes to the as-signment of value to concepts in the model.Specifically, concepts are characterized bydominance or importance.22 Depicting DIKWas a pyramid is suggested as a means ofproposing a consolidation of power in the up-per levels from the lower levels.20,22 In nurs-ing informatics, DIKW is not visualized in thesame way. However, a side-by-side compari-son of visualizations illustrates similar featuresof the models (see Figure 6). Notably, the vi-sualization of DIKW in nursing informatics de-picts a similar allusion to linear and “positive”growth, a hierarchy among concepts, and aconsolidation of effect in the movement fromdata to wisdom.

In the field of geography, Poore and Chris-man outline the problematic nature of thisdepiction of DIKW, asserting that “the in-formation pyramid embodies and normalizestheories of power, reflecting the hierarchi-cal social structures of the old industrialeconomy.”23(p511) They suggest that the valu-ing of concepts in DIKW has the potential tospill over and unintentionally be seen to ap-ply to individuals and professions, “with man-ual workers on the bottom and knowledgeworkers and bosses on the top.”23(p511) Fur-thermore, depicting knowledge and wisdomas higher up in the traditional nursing infor-matics depiction of DIKW suggests that theyare more valuable than data and information.

Indeed, a premise of DIKW is the move-ment toward wisdom as the ultimate goal.Fricke suggests that this depiction of DIKWis reminiscent of “inductivist growth-by-accretion model of science” that has largelybeen abandoned—thanks to the work ofPopper and Kuhn demonstrating the fallibleand value-laden nature of knowledge—in fa-vor of accepting that “even the most cher-ished of ‘pure observational facts’ is open tothe possibility of revision.”18(p6)


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Figure 7. The DIKW model as depicted by Looman et al.14 DIKW indicates data-information-knowledge-wisdom.Reprinted with permission.

The notion of data eventually consolidat-ing into wisdom is problematic in a numberof ways. For one, it reflects outdated ideals re-lated to how science develops, as mentionedpreviously. Second, the question arises of justhow the movement from data to wisdomtakes place—what causes the movement? Isthere an innate inertia that moves, consoli-dates, and transforms data across the otherDIKW concepts to reach the pinnacle of wis-dom? In the field of medical informatics, Geor-giou critiqued the underlying assumptions ofthe informatics model, stating that

“It [the informatics model] is . . . founded on somequestionable assumptions, particularly if the pro-cess of data/information/knowledge is viewed lin-

early, whereby the mere capture of data on oneside of the spectrum can lead seamlessly to infor-mation and then knowledge. In reality there area number of interrelated activities involved in thegeneration of information.24(p128)

Although these criticisms draw from thepyramid structure, the similar hierarchicalstructure alluded to in the nursing informaticsmodel of DIKW warrants concurrent consid-eration of this criticism.

Another salient critique of DIKW relatesto the linear movement between conceptswithin the model. These are, arguably,shaped by the values attributed to eachof the concepts of DIKW. The depictionof DIKW suggesting linear, unidirectional


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movement between concepts has beenchallenged. Various authors have highlightedthe lack of consensus and varying viewson how DIK is defined, bounded, andcreated, positing instead the possibility forbidirectional movement between concepts asnecessary.17,25,26

Indeed, this criticism of linearity is amongthe first addressed in the evolving iterationsof DIKW in nursing informatics, resulting inrevisions to the model to indicate the possi-bility of bidirectional movement across DIKW(see Figure 3), which we elaborate on furtherlater in this article. Nevertheless, problematicaspects of DIKW related to linearity and hi-erarchy remain. Gee et al13 attempt to man-age this issue by allowing for movement backand forth; however, the Gee et al model re-tains a sequential format and does not allowfor the possibility of relationships betweenconcepts not adjacent to each other, for in-stance, between wisdom and data. The modelpresupposes that each component must “gothrough” the other to move to the next step.However, in what follows, we explore howthis sequencing may not necessarily be re-quired.

Related to the restrictions of linear move-ment in depictions of DIKW, a further pointof criticism addresses an implicit restrictionof movement within the model—specifically,the suggestion that all movement must be-gin from data, understood to be the buildingblocks underpinning the model. Various au-thors have argued that this view is problem-atic in that it neglects to take into account con-textual factors that influence where the be-ginning point on the DIKW continuum is andin which direction movement should flow.For instance, Tuomi26 suggests that the direc-tion of movement between concepts in DIKWwill vary depending on whether the user isa knowledge seeker or knowledge creator.Knowledge seekers place data into contextto create information and make these action-able in knowledge, much in line with “tra-ditional” descriptions of DIKW.26 However,Tuomi26 also highlights that behavior andmovement through DIKW differ for knowl-

edge creators who begin with knowledge tocreate information, which are then neededto create data. Similarly, it is suggested thatknowledge and information must exist asprerequisites to create the specific contexts,structures, and semantics that facilitate cre-ation of data.26 Tuomi26 goes even further tosupport the argument that data are more im-portant than knowledge, proposing an inver-sion of the DIKW hierarchy with data placedat the top.

The valuing of knowledge as something ei-ther to be mobilized or to be created is arguedas a means to shape “how we know whatwe know” and to understand what kinds ofknowledge are possible.27 In addition, the di-versity in definitions and conceptualizationsof hierarchy in DIKW suggests that valuesplay an important role in determining direc-tionality in DIKW. There is arguably an inex-tricable connection between epistemology—the nature of knowledge—and axiology—the ways that values are attributed, in shap-ing perceptions of knowledge creation andutilization.26,28,29

Some critiques of DIKW in the broaderliterature have been similarly recognized innursing informatics by the ongoing refine-ment of representations of DIKW. For in-stance, various iterations modified the ini-tial DIKW model in nursing, with later ver-sions of the model incorporating bidirectionalmovement between concepts, referred to as“constant flux,” indicated by double-ended ar-rows that span the concepts of DIKW.5 Themost recent modification of DIKW by Nel-son goes even further in attempt to clearlydepict the potential for bidirectional move-ment between adjacent concepts in DIKW.The notion of “constant flux” is revised: ratherthan having 1 bidirectional arrow spanningthe model, the authors instead include 2 bidi-rectional arrows between adjacent concepts.This latest revision of the model suggeststhe possibility of overlapping and interrelatedmovement between concepts, and the possi-bility for treating data as information, and viceversa, depending on context.4 For example,Nelson and Staggers4 suggests that a novice


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may view a patient’s laboratory result as datawhereas an expert may view that result inthe context of the patients’ overall status, andthe expert’s interpretation of the data pointas information may cause the expert to al-ter the patient’s plan of care. The Loomanet al14 adaptation of the DIKW framework ad-dresses the problem of linearity by depictingDIKW as underpinning a model of care coor-dination. In their article, they do not explic-itly state that they are attempting to managethe linearity problem; however, their adapta-tion implies that the hierarchical model wasof limited usefulness for operationalization ina research study.

Overall, the critiques and adaptations innursing informatics we have sketched out ear-lier indicate the continued relevance of DIKWand, arguably, illustrate the continued evolu-tion required to address the challenges andlimitations in understanding and using themodel. To further contribute to understand-ing DIKW and its utility in nursing informatics,however, the issues related to the assignmentof values to DIKW concepts and the poten-tial of beginning in a place other than data,and the implications arguably, should be ad-dressed.

IMPLICIT PHILOSOPHICAL GROUNDINGOF CONCEPTS IN DIKW

In addition to critiques of the linear and hi-erarchical nature of DIKW, the implicit philo-sophical groundings of DIKW are arguably an-other problematic feature of the model. Inparticular, numerous critiques in the field ofinformation science have pointed to the strictand narrow definitions of the concept of dataand its seeming incommensurability with therealities of data in practice or application—namely, data as not always easily clearly de-fined or distinguished from information andknowledge.18,30 In the DIKW model, data areviewed as the most basic and fundamentalbuilding blocks of knowledge, information,and wisdom. In addition to pointing to dataas the basic component from which all the

other concepts build on, primacy is also be-ing given to a very specific view of data.

The logical flow in DIKW suggests that allknowledge and wisdom ultimately stem fromobjective, value-free, and “pure” data.2,6,18

However, a growing number of critiques havehighlighted the limitations of this view andhave argued for the impossibility of data exist-ing without context, or being generated with-out prior knowledge.18,26 Recently, growinginterest in Data Science and Big Data has re-cast the role of data. Briefly, Big Data re-fer to massive data sets composed of enor-mous amounts of data, now being routinelycollected as a result of the ubiquity of com-puting. Data Science centers on the develop-ment of innovative computational techniquesto analyze these massive data sets that in-clude data harnessed via the Web (eg, Googlesearch queries and Facebook behavior pat-terns, electronic health record repositories,insurance claims, consumer reports, and mo-bile phone usage patterns).31,32 Big Data an-alytics are already being used as a power-ful decision-making tool—it is through BigData, for example, that Google can predict in-fluenza outbreaks and unemployment trendsprior to release of official statistics, basedon the search terms and timing and loca-tion of search queries.33 Returning to the roleof data, Kitchin34 suggests that specific per-spectives and contexts, disciplinary or oth-erwise, determine how data are conceptual-ized and used. Whereas to a physicist, datamay be simply composed of zeroes and onesand innately meaningless until patterns areformed,34 to a nurse, data may be less dis-crete and require contextualization (eg, deter-mining which physiological data are relevantwhen observing for impending shock).

Building on these critiques, it can be ar-gued that these assumptions of the roleand nature of data are contingent upon theobserver’s particular ontological, epistemo-logical, and axiological stance. Briefly, ontol-ogy is used here in the philosophical sense,referring to the nature of existence and asksthe question “what exists?” or “what is?”27

and axiology refers to the theory of values,


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includes ethics (what is “right” and “good”;“what ought to be”) and aesthetics (beautyand harmony).35,36 To expand, consider thefollowing scenario. Two people, person A andperson B, are presented with the question:“What is the most basic unit of knowledge?”Person “A” may lean toward a modified re-alist ontology in his or her view of DIKW.Modified realism accepts the existence ofan objective “real world” that exists inde-pendently of human thought and knowledgebut accepts that knowledge of this worldis fallible.37 Accompanying person A’s real-ist ontology is an objectivist and social con-structionist epistemology. In other words, theacceptance of a meaningful objective real-ity (objectivism) accompanied by a simul-taneous acknowledgment that knowledge,meaning-making, and representations of the“real world” are socially constructed (socialconstructionism).27,37 That is, history, cul-ture, and social phenomena contribute tohow the “real world” is described and under-stood. In terms of values (axiology), person Amay place primacy on accurately measuringobservations and get as “close” to the “realworld” as possible while acknowledging theimportance of recognizing the significance ofcontext. Therefore, when turning to the ques-tion of the basic unit of knowledge, person Awould likely agree with current descriptionsof DIKW wherein data are treated as the mostfundamental unit, as they represent measure-ments and observations that get as close tothe “real world” as our senses and instruments(ie, extensions of sensory information) can al-low. However, person A would also acknowl-edge that taking up data as pure “fact” is er-roneous, as “fact” is also influenced by thecontexts that shape the larger phenomenonbeing addressed.

In contrast, suppose that person B leanstoward a more relativist ontology in view-ing DIKW. This ontological stance rejects thenotion of “truth” or a “real world” and sug-gests that there is no objective meaning in theworld.27 Person B also holds a constructivistepistemology, which posits that meaning onlyarises when humans interact with the world

and ascribe meaning to things. Furthermore,meaning-making is deemed to be shaped byunique experiences of individuals, recogniz-ing that individuals inhabit different worlds.27

Accompanying these ontological and episte-mological stances is the axiological valuingof individual experience and understanding,as instrumental in creating knowledge. Posedwith the same question of what comprises themost basic unit knowledge, person B wouldlikely reject the definition of data as definedby DIKW, as there are no universal truths. In-stead, data would be widely varied and notbe condensed simplistically into categories.Indeed, the notion that individual experienceand meaning-making is reducible to measur-able data would be problematic in and of it-self. Person B may altogether reject the ideathat the DIKW model affords room for indi-vidual meaning-making, given that it is basedupon a strict definition of data.

These opposing scenarios presented ear-lier, although simplified, illustrate how spe-cific ontological, epistemological, and axio-logical stances taken by individuals ultimatelyshape how the hierarchy that is implicit inthe DIKW model might be interpreted. Fur-thermore, a key point to highlight here is thatit is not “good” or “bad” that data are treatedas value-free or contextualized but rather theimportance is in being cognizant of the con-ceptualizations of data being used, as theseconceptualizations ultimately influence fur-ther ways of producing and using these data.

Taking this philosophical stance in under-standing the implications of assumptions inDIKW is particularly salient in nursing work,where a plurality of perspectives and ap-proaches to developing and using knowledgefor patient care exist.28 Indeed, the impor-tance of being cognizant of these implicit as-sumptions is further highlighted upon return-ing to Graves and Corcoran’s article. Recog-nizing the limitations of technology to processonly empirical knowledge at the time, the au-thors pointed to the need to explore waysof incorporating, managing, and supportingCarper’s38,39 4 ways of “knowing” (empirical,ethical, personal, and aesthetic) in the study


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of nursing informatics, as the latter 3 are lessdiscrete and cannot be easily processed.

In one of the few articles that takea philosophical approach to examiningthe DIKW model, Matney and colleagues6

proposed that the epistemological basis forunderstanding the model can be under-stood collectively through postpositivism (be-lief of a “real” world while acknowledging“the social aspects of reality”) and Gadame-rian hermeneutics (interpretation with fo-cus on “the centrality of language and dia-logue to understanding”). The author suggeststhat data and information can be under-stood through a postpositivist epistemologywhereas knowledge and wisdom can be un-derstood through hermeneutics.6 However, aquestion this brings forward is how a modelcomprising concepts whose foundations dif-fer ontologically—namely, objectivism (dataand information) and something closer torelativism (knowledge and wisdom)—can beunderstood to be cohesive? In particular,how can such a composite model be madecommensurable, given the linear logic argu-ment made in DIKW visualizations that eachconcept builds on the other (ie, data be-come information, which becomes knowl-edge, which becomes wisdom)?

WHAT OR WHO IS DIKW MEANT TOSERVE?

To address the aforementioned question,we look to literature in nursing informaticsthat delineates the nurse as playing an inex-tricable role in DIKW.2,3,5,6 Descriptions ofDIKW often refer to a prominent role of thenurse who incorporates additional informa-tion and knowledge such as clinical experi-ence, tacit knowledge, and intuition and alsodraws from data and information to arriveat the more complex knowledge and wisdomcomponents of the model. To better under-stand the relationship and potential dynam-ics between nurses and computerized clinicalinformation systems as related to DIKW, weargue that an important clarification in con-

sidering using or applying DIKW is related towhat or who the model is meant to serve.

Without clear delineation of who or whatthe DIKW model is meant to serve, it is diffi-cult to determine which concepts are meantto refer to functions of computerized clini-cal information systems (ie, systems used tomanage clinical information required for nurs-ing practice), which concepts refer to func-tions and actions of nurses (ie, as users in-teracting with the system), and where theyapply to both or overlap. This lack of claritycontributes to the challenges in understand-ing the applicability of DIKW. Arguably, howDIKW is interpreted and taken up can bemore clearly understood when situated in aspecific context (ie, in information systemsor in nursing practice).

DIKW FOR COMPUTERIZED CLINICALINFORMATION SYSTEMS

The applicability of DIKW in understand-ing the use of computerized clinical informa-tion systems appears clearer in comparisonwith its utility in human information process-ing. Machlup notes, “When we talk aboutdata in information science, we basically re-fer to ‘things fed into a computer.’”40(p647) In-deed, the appeal of DIKW relates to its fit withthe way computers process information. Inthe context of computerized systems, it is log-ical and necessary to view data as value-freefacts that are observable and measurable in or-der for computerized information systems tofunction. Furthermore, the propositions thatdata are basic, discrete, “building blocks,”processed data and addition of contextcreates information, and synthesizing infor-mation and identifying patterns and relation-ships create knowledge are features that canbe programmed into computerized clinicalinformation systems.3,6 Nelson and Staggers4

effectively illustrate how DIKW can be usedto understand automated systems at differentlevels of sophistication, from informationsystems to decision support systems andexpert systems. In contrast, the possibility of


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developing computerized clinical informationsystems that include features of the complexconcept of wisdom remains uncertain. Al-though various definitions and interpretationsof wisdom exist, authors similarly liken wis-dom to a state of peak human performancethat transcends mere knowledge andinformation.19 This suggests that wisdomrequires drawing from multiple types ofknowledge (with diverse ontological andepistemological foundations, history, expe-rience, and axiology),4,6,19,20 features thatcannot be simplistically programmed intocomputerized clinical information systems.In fact, it was in questioning the possibilityof programming computerized managementinformation systems to demonstrate wisdomthat motivated Ackoff’s12 initial introductionof the DIKW hierarchy. While the discussionof efforts to develop intelligent systems(eg, IBM’s Watson cognitive system)41 mayeventually demonstrate characteristics ofwisdom, such discussion, while beyondscope of this article, may be important formonitoring and tracking future developmentsin computerized clinical information systemsin the context of DIKW.19

DIKW FOR NURSING PRACTICE

In contrast to the relative ease that DIKWcan be applied to computerized clinical infor-mation systems is the understanding of DIKWas applied to the context of nursing practiceand human information processing. Specif-ically, focusing on the concepts of “value-free” data—as the foundation upon whichthe model stands—and knowledge—as issuesaround nursing’s pluralistic epistemologies—is especially important, given that knowledgeis portrayed as a precursor to wisdom. Nel-son and Staggers4 suggest that humans can beunderstood as open systems who take in, pro-cess, and output concepts of DIKW and pointto learning theory as a framework for under-standing this process. However, this stancedoes not address axiology and assumes theseparation of human understanding from as-cribing value to what counts as DIKW. Given

that nursing has an axiological (ethical) man-date to serve diverse—and often vulnerable—populations, being clear about our values-based purpose is crucial.28

It is difficult to make the case that humanconceptualization and use of data—the foun-dational “bedrock” of the DIKW model—cantruly be viewed as discrete, objective, andvalue-free, as the definition of this conceptand the succession toward subsequent levelsof the model necessitates. The concern hereis similar to a concern articulated by Ma, fromlibrary science, who states:

For humans, information and knowledge are notprocessed data; rather, we learn by being situ-ated within and understanding complex webs ofrelations of persons, events, social and politicalstructures, and many other things. Further, weseek agreement with each other on what thingsmean through learned social and cultural toolsand categories . . . . The analogy of data to hu-man stimuli and machine process output to knowl-edge is a bizarre analogy that obfuscates ratherobvious difference between designed and organicagents.20(p720)

The suggestion of understanding humansas open systems that incorporate DIKW isalso problematic in that there is an asser-tion that data exist “out there” independentof context, ready to be absorbed and assim-ilated by human information processing. Asargued earlier, what is considered “data” can-not be separated from axiology and contextand, currently, the limitations as to what canbe considered data are particularly significantin nursing. Consider the concept of pain innursing practice: Does the perception of paincount as data? If so, what would be the funda-mental unit of measuring perception of pain?The realist ontological stance that the defini-tion of data seems to be based upon wouldsuggest that to understand pain, one mustbuild from objective indicators of pain thatexist, independent of interpretation and hu-man thought. Therefore, would the only validmeasure of pain be an increase in heart rate,diaphoresis, or other “objective” somatic mea-sures? What would this then mean for nursingknowledge that “pain is whatever the person


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says it is” and the body of research that val-idates the knowledge that self-reported painis most accurate, with physiological and non-verbal measures considered less reliable?42,43

This example illustrates only a few of theunavoidable complexities and limitations ofunderstanding data as it is currently narrowlydefined in the DIKW model.

Next, consider the concept of knowledge.In the DIKW model, knowledge is describedas a product of pattern recognition, identifi-cation, and formalizing of interrelationshipsbetween various types of information.3,6,44

However, this depiction of knowledge doesnot align with developments around episte-mological understanding and plurality, par-ticularly in the context of nursing practice.Graves and Corcoran2 began to point to lim-itations of DIKW with regard to incorporat-ing the 4 “fundamental patterns of know-ing” as identified by Carper38,39: “(a) empir-ics, the science of nursing; (b) esthetics, theart of nursing; (c) the component of a per-sonal knowledge in nursing; and (d) ethics,the component of moral knowledge in nurs-ing.” Graves and Corcoran2 highlighted that,at the time, conceptualizations of knowledgein DIK referred only to empirical knowledge.They therefore pointed to the need for fur-ther development in incorporating the othertypes of knowledge central to nursing: aes-thetics, personal knowledge, and ethics.

Nursing discourse around knowledge hasdeveloped substantially since Carper’s initialwork, and the history of knowledge develop-ment in nursing illustrates wide-ranging epis-temological diversity. Much of the work re-lates to the explication of the types of know-ing outlined by Carper; the development ofnursing as a science; the emergence of nurs-ing theories and frameworks; the incorpora-tion and application of interpretive and crit-ical approaches; and the growth in promi-nence of evidence-based practice.28

Despite the developments in our under-standing of the nature of knowledge andrecognition of the distinctive epistemologi-cal diversity and information processing usedby nurses, there is yet to be evidence that

Graves and Corcoran’s2 suggestion of incor-porating an expanded view of knowledge hasbeen incorporated in contemporary under-standings of DIKW. Arguably, many descrip-tions of DIKW suggest that reaching wisdomrequires the marriage of not only differenttypes of knowledge but also of experience,history, context, values, ethics, and aesthet-ics, suggesting that nursing intuition and tacitknowledge may have valuable contributionsto the DIKW model that have remained fairlyunexplored.

DIKW WITH A DUAL PURPOSE

In much of the literature, reference toDIKW in nursing suggests that it is under-stood as applicable to both systems and nursesas users, perhaps concurrently. DIKW is dis-cussed as a model used for nursing informat-ics, but it is unclear if this refers to the com-puter system or the nurse working with it. Al-though not explicitly articulated, descriptionsof DIKW likely presume a fluid relationshipbetween computer system and the nurse andview the interaction between both as part ofa larger system. Nevertheless, role boundariesand contributions of both the computer sys-tem and the nurse will vary depending on thenature and purpose of the computer system,the nurse’s familiarity with the system and re-lated factors (eg, complexity of technology,nurse’s level of digital literacy), and the con-text within which the interaction betweenthe nurse and the system takes place. For ex-ample, consider again the concept of pain.In the case of a simple computerized clini-cal information system, the system may pro-cess raw data (diaphoretic, 140, heart rate,wincing) to put out information (heart rate =140 + diaphoretic + wincing = pain?*). Thenurse may then be expected to incorporate

*This simplistic example serves only to illustrate the au-thors’ point and presumes the nurse’s comprehensiveassessment of the situation to rule out that another po-tential reason (eg, pulmonary embolus) has taken place.


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this information either into a broader knowl-edge base (signs of pain + recent surgery =need for acute pain management) or into a his-tory of observations to facilitate actions thatdemonstrate wisdom (the patient who under-went recent surgery with frequent complaintsof pain uncontrolled by current medicationssuggests the need to revise pain manage-ment). In the case of a more advanced clin-ical information system, the system may dis-play characteristics of knowledge by recog-nizing complex patterns and creating recom-mendations (frequency of pain medicationadministration + dosage + type of drug =suggestion of change in the type of medica-tion). The nurse can then draw from his orher own knowledge base to assess the sys-tem’s recommendations (ie, evaluate systemrecommendation in relation to history of tol-erance to newly recommended medication)and to apply wisdom in deciding whether ornot to pursue the system’s suggested recom-mendation (patient’s history suggests poor ef-fect of newly suggested medication combinedwith nurse’s recognition of the subjectivityof all pain experiences), leading the nurseto explore alternative options or augmentwith nonpharmacological approaches to painmanagement that have provided relief inthe past).

In a similar example, Nelson and Staggers4

describe the potential variability in treatingsomething as data, information, or knowl-edge, depending on the individual. Whereasa novice nurse may treat something as data,a more experienced nurse may treat it asinformation.4 These examples illustrate thevariability in the application of DIKW as re-lated to potential combinations of how thecomputer systems and nursing practice mightfunction. The lack of clear demarcation whereDIKW is concerned with computerized clini-cal information systems and where it is con-cerned with the nurse, and the role and con-tributions of each, arguably creates challengesin understanding how the model is meant tobe taken up and applied and what purpose itserves. The fluid dynamics between the rolesof the computerized clinical information sys-

tems and the nurse appear implicit in DIKWNevertheless, delineation of which conceptsrefer to the computerized clinical informationsystems, the nurse, or both, whenever possi-ble, can provide guidance as to how DIKWcan be understood and applied.

WHAT LEVEL OF THEORY DOES DIKWESPOUSE?

The second guiding question offered in thisarticle is the consideration of the level of the-ory in DIKW. This aspect of DIKW has notbeen critically examined, yet this question hasmany important implications for the under-standing and application of the model, par-ticularly given the nursing’s history relatedto theory building. Nursing’s transition froman apprenticeship model to a scholarly prac-tice discipline spurred a substantial interestin establishing disciplinary boundaries that in-cluded development of various nursing theo-ries, beginning in the 1950s to the 2000s.45

Following this work was the attempt to un-derstand and tease apart various “levels” oftheory within nursing to gain clarity of theirpurpose and application.45,46

It is important to acknowledge that di-verse referents of the word theory can causeconfusion, and it is beyond the scope ofthis article to delve deeply in this discus-sion. For guidance, however, Higgins andMoore46 suggest that it is more useful to usethe terms “theory,” “theoretical/conceptualmodel,” “theoretical framework,” and “theo-retical system” interchangeably, with the ad-dition of modifiers such as “grand” or “mid-dle range,” to describe a theory’s fit amongother theoretical work.* In contrast, Nelson

*A meta-theory is a theory of theories that examines over-arching theoretical approaches to inquiry and addresses“questions science cannot answer.”46,47 A grand theoryis an abstract theoretical system that attempts to providea universal explanation for a complex phenomenon.4,46

A middle-range theory attempts to explain specificallydefined phenomena and can be either explanatory orpredictive.4,46 Middle-range theory has a lower level of


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and Staggers4 make clear distinctions differ-entiating between theory and conceptual andtheoretical frameworks and models and referto DIKW as one of many theoretical mod-els (ie, a visual representation of a theoreti-cal framework) of information theory. For thepurpose of this discussion, theory is definedas “the creation of relationships among twoor more concepts to form a specific view ofa phenomenon.”46(p179) Arguably, the currentconceptualization of DIKW in nursing infor-matics falls under this definition of a theory, as(1) it suggests specific relationships among itsconstituent concepts; and (2) the relationshipbetween concepts suggests a specific processthrough which wisdom is arrived at. Giventhe limited critical examination of DIKW innursing informatics, it is arguable that some ofthe challenges in understanding the utility andapplicability of DIKW that have been high-lighted stem from the description of DIKWas a grand theory yet incorporating conceptsand features of middle-range theory.

DIKW falls under the criteria of a grandtheory, as it outlines a theoretical frameworkof abstract concepts with specific relation-ships that attempt to explain a specific phe-nomenon (the movement from data to wis-dom), with limited capacity for empirical test-ing. However, DIKW also has features ofmiddle-range theory such as having implicitphilosophical assumptions, being sufficientlygeneral to cross multiple clinical populations,and providing specifics to guide research andpractice.46 DIKW explicitly outlines each stepof the theoretical framework and providesclear direction as to how data can be pro-cessed and transformed from discrete entitiesto components of a complex knowledge baseand further, describing how arriving at wis-dom ultimately guides clinical practice and de-cision making. Although DIKW can be viewed

abstraction and is empirically testable, whereas grandtheory is at a higher level of abstraction and is nottestable.48 Finally, micro-range theory is the most nar-row in scope and can take the form of a specific researchhypothesis.4,46

as an explanatory middle-range theory, it doesnot meet the criteria for empirical testability.Specifically, the means through which to mea-sure or observe the transformation from datato each subsequent is unclear. In addition, thediversity of ways that wisdom is conceptual-ized and modeled would suggest different ap-proaches to its measurement and confoundedby the added complexity of placing it in con-text of the DIKW theoretical model.19

The notion that DIKW lies somewhere be-tween a middle-range theory and a grand the-ory is supported by Nelson and Staggers, whosuggest that theoretical frameworks can be“conceived as a bridge between a middlerange theory and a grand theory.”4(p19) In-deed, it may be the case that DIKW is sim-ilar to Jean Watson’s Philosophy of Scienceand Caring and Madeleine Leininger’s Cul-ture Care: Diversity and Universality The-ory, where no consensus has been reached onwhether it is grand or middle-range theory.46

Considering this possibility, one way of re-framing how DIKW is viewed is to see it as anindicator of the evolution of disciplinary nurs-ing knowledge.46 DIKW is well entrenchedin nursing informatics and perhaps some ef-fort in revisiting this theoretical model maybe worthwhile. Further explication and de-lineation the levels of theory incorporated inDIKW can highlight important questions. Po-tential avenues for inquiry include investiga-tion of what components of DIKW are em-pirically testable, the development of mea-sures and tools to test the theoretical model,and the exploration of conceptual modelsthat are perhaps embedded within the largerframework. Indeed, these and other pointsare addressed in some recent attempts in mov-ing forward with the continued evolution ofDIKW in nursing informatics, as will be de-scribed in the following section.

CONCLUSIONS

The proposed flexibility in the most recentDIKW model illustrates the ongoing develop-ment and progress in the understanding andattempts to operationalize DIKW in nursing


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informatics. Building on the ongoing work onthe evolution of DIKW, this discussion arguedthat the perspectives of DIKW in nursing in-formatics might be made richer with the in-corporation of the criticisms of DIKW fromdisciplines outside of nursing, for example,the critiques of linearity and hierarchy as out-lined by Tuomi26 and Faucher et al17 fromthe field of management information systems.Similarly, criticisms from the field of informa-tion science highlighted the implications ofthe philosophical underpinnings of DIKW onits potential application.

In this discussion, 2 key guiding questionswere offered, with the aim of clarifying un-derpinnings of DIKW, so that its applicationmay be better informed. First, the questionof who or what DIKW is meant to serve hasbeen elucidated, highlighting the differencesand implications of DIKW as applied solely tocomputerized clinical information systems, asapplied solely to nursing practice, and as ap-plied to systems that incorporate both. Thesecond guiding question involved the ques-tioning and examining of the level of theoryDIKW is thought to occupy (ie, somewherebetween a grand theory and a middle-rangetheory) and how this lack of clarity, in thepast, has likely contributed to some of thechallenges in applying and operationalizingDIKW.

Alternatively, perhaps DIKW can beviewed as a vision or goal for nursing in-formatics: a depiction of nursing informat-ics as a vehicle in the movement towardnursing praxis. In other words, using nurs-ing informatics to arrive at “theory and prac-tice that are interrelated, integrated, and di-alectal in nature”49(p126) and that has as aninherent component “the notion of reflec-tion upon practice toward the refinementof theory and therefore the enhancement ofpractice.”50(pxii) In this view, we would thenbe directed to taking up DIKW as a meansof understanding nursing informatics, inclu-sive of both computerized clinical informa-tion systems and nurses as users, since nurs-ing praxis would require both components.In addition, if DIKW is understood to be a

vision for nursing informatics in moving to-ward nursing praxis, further development ofthe model is needed to better explicate thecomplexities that are unaddressed in its cur-rent visualized form.

It is worth highlighting that continued in-terest in the concepts in DIKW remains innursing informatics. The most recent workby Matney15 on the development of the The-ory of Wisdom-in-Action for Clinical Nurs-ing can be seen as an exemplar of movingthe concepts within DIKW forward, particu-larly the much understudied concept of wis-dom. Matney’s theory proposes person- andsetting-related factors as antecedent dimen-sions of wisdom and 2 types of wisdom pro-cesses: general wisdom-in-action and personalwisdom-in-action. We argue that part of whathas facilitated the clarity and operationaliza-tion in Matney’s theory development includesmeeting the clearly and explicitly addressingthe 2 guiding questions brought forward inthis article: (1) who/what does it serve (theTheory of Wisdom-in-Action specifically looksat clinicians in practice); and (2) the cleardelineation of the level of theory it aims at,specifically, as a mid-range theory that is po-tentially testable.

Works such Matney’s15 Theory of Wisdom-in-Action and philosophical approaches toDIKW,6 as well as application of DIKW byGee et al13 and by Looman et al,14 suggestthat part of the continued attraction of DIKWin nursing informatics is its ability and con-tinued potential for making visible aspects ofnursing work in the move toward increas-ingly digitized systems. Although not with-out its challenges, perhaps taking differentphilosophical approaches to understand var-ious components of DIKW as suggested byMatney and colleagues,6 is one way of mov-ing forward, making possible the potentialfor eventually including and operationalizingCarper’s ways of knowing in nursinginformatics.

Finally, we point to the potential for mov-ing toward more interdisciplinary dialogue,as related to DIKW. At this time of writing,we are unable to identify any articles that


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use or examine DIKW from more than 1 dis-ciplinary perspective and highlight this as apotentially fruitful area of inquiry in the fu-ture. At the outset of this article, we positedthat an approach such as DIKW can pro-vide a common language and coordinationof individuals from various disciplines (eg,nursing, computer science, information sci-ence, medicine). In closing, we would notethat true interdisciplinary dialogue, wherewe “analyze, synthesize, and harmonize thelinks between our disciplines into a coordi-nated and coherent whole,”51(p351) is required

if we are going to be able to enhance thedevelopment and application of the DIKWmodel for health care overall. We hope thisdiscussion further contributes to continuingunderstanding of DIKW in nursing informat-ics and its evolution and toward the goalsof nursing informatics to be able to incor-porate different types of knowledge in nurs-ing as part of computerized clinical informa-tion systems, as initially described by Gravesand Corcoran, and toward the larger goal ofnursing informatics of making nursing workvisible.

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