Computers were introduced into nursing care areas in the early 1950s.1 Later in 1982, the Capital Area Roundtable on Informatics in Nursing, a group of nurses focusing on use of information technology in healthcare, was established. In the same year, the International Medical Informatics Association (IMIA) established the Nursing Informatics Special Interest Group. A year later, the first journal focused on nursing informatics, now called CIN: Computers, Informatics, Nursing, went into publication. Since then, the term “nursing informatics” has emerged in nursing scholarship.2–5 Throughout the development of the field, many have described informatics as including conceptual components such as information collection and information utilization.6 The most current version of the American Nursing Association's Nursing Informatics Scope and Standards of Practice defines nursing informatics as “the specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice.”7(p1) Because of the emerging nature of the field, much discussion related to the exact definition of nursing informatics continues to exist among informaticists. Nevertheless, nursing informatics is still an expanding field, on the “evolutionary journey”, meaning that new challenges will arise.8
Knowledge is built and developed with references to the past.9 Indeed, Palmer and Colton10(p118) claim that the “major value of history, historians, and methods of historical thinking is not in their contribution of and to things past, but in the knowledge and involvement history establishes in everyday people in everyday world.”
The history of nursing informatics has been studied and reviewed by scholars in the field. Most notable reviews were done by Saba1 and Ozbolt and Saba.11 However, some nursing informatics historical timelines can be found in gray literature.12–15 Gray literature is defined as “…manifold document types produced on all levels of government, academics, business, and industry in print and electronic formats that are protected by intellectual property rights, of sufficient quality to be collected and preserved by library holdings or institutional repositories, but not controlled by commercial publishers, i.e., where publishing is not the primary activity of the producing body.”16(p12) In addition, some professional organizations have supported nursing informatics history projects that contain text examples, video recordings, and images.15
Contrary to previous studies, which used manual review of the nursing informatics literature, we employed an automated, electronic approach to analyze the history of knowledge development in nursing informatics. The approach used in this was based on distant reading, a radical approach, introduced by the literary scholar Moretti.17 In distant reading, the objective is to analyze literature through aggregating and analyzing vast amounts of data derived from texts using computerized methods. The main advantage of this approach is that one does not need to read the enormous amount of available literature and extract needed data or information manually, but uses the computer and data mining to perform these tasks.18 In the analysis of scientific literature, distant reading is performed by bibliometric analysis,19 which is the application of quantitative analysis (statistical and mathematical) to bibliographic features of research literature production.20,21 The overview of the successful employment of bibliometrics in nursing is presented by Kokol and Blažun Vošner,22 and Herubel,23 adding the time and space dimension, introduced the historical bibliometric analysis. The purpose of this analysis was to describe the dynamics of literature production, identify the historical roots, and reveal the evolution of topics and themes in nursing informatics.
Historical roots are important publications in a specific research area (SRA), which have been cited most frequently in the corpus of SRA publications.24 While the number of SRA citations might differ from the total number of citations reported in abstract and citation databases such as Web of Science or Scopus, a specialized software called CitedReferenceExplorer (CRE) (University of Applied Sciences for Telecommunications Leipzig, Leipzig, Germany) was used. In addition to Reference Publication Year Spectroscopy (RPYS), it uses other indicators described in the following paragraphs to identify historical roots.25–27 The CRE analyses reference publication years and then aggregate them over time in the form of a spectrogram. Like the spectra in natural sciences, where peaks represent certain phenomena, CRE peaks indicate historical roots. The CRE tabular output was used to identify historical roots for the “little science period”25 (until the year 1950), and the CRE spectrogram peaks after that (“big science period”). Inclusion criteria for historical roots in the “little science period” required that articles be cited at least three times, the most cited publication in the year in which they were published, and directly or indirectly related to information processing. Additional CRE indicators, namely, N_TOP10 (publications that were in the top 10% of the most cited publication over 15 years) and “sleeping papers” (SP), which were defined as undercited in 2 of the first 3 years after publication, overcited in at least 1 year after that, and reached 40 or more citations, were also used in the analysis.28
For the exploratory bibliometrics portion of the study, VOSViewer bibliometric mapping software (Leiden University, the Netherlands)29 was employed to induce the cluster and timeline landscapes for three periods: (1) first citation until 2004, (2) 2005 until 2014, and (3) after 2014. The cluster landscape was used to analyze the evolution of themes through the three periods.30,31 The timeline landscape was used to analyze the evolution of topics and health problems addressed by the nursing informatics movement.
Data Source and Corpus
The initial search was performed in Scopus (Elsevier, the Netherlands), the largest abstract and citation database of peer-reviewed literature. The corpus was formed on December 26, 2018, using the search string “nursing informatic”* in information source titles, abstracts, and keywords, limited to the “subject area = nursing.”
Data Extraction and Analysis
Using the built-in functions, the publication titles, source title, publication type, abstracts, publication years, and references were exported to the MS Excel (Microsoft, Redmond, WA), VOSviewer, and CRE software tools. From there they were further analyzed. Using a customized VOSViewer thesaurus file, common terms like study, baseline, control group, trend, method, table, significance, description, and average; country and city names; time stamps from the analysis; and mapped synonyms into one entity (eg, nursing and nursing care into nursing) were excluded.
The search resulted in 3805 publications. The first two publications indexed in Scopus were published in 1962, dealing with automated retrieval, and abstracting and indexing of biomedical literature.32,33 After that, through 1976, when a slight rise occurred, publications were scarce, with one publication per year at the most. The linear growth began in 1983, ending in 1992. Interestingly, two peaks with 14 and 41 publications appeared in the linear growth period in 1984 and 1989, respectively. Linear growth was followed by logarithmic growth, reaching its peak in 2015 with 244 publications. A significant drop in literature production was noted in this period, from 200 to 149 publications in the years 2005 to 2010. After 2010 to 2015, a sharp decline followed, reaching minimal productivity in 2018 with 136 publications. Figure 1 offers an illustration of these results.
The corpus contained 69 824 references. After removing duplicates and references with missing or invalid publication year, 57 057 references remained. Fifteen historical roots of nursing informatics were identified (Figure 2 and Table 1). The two oldest historical roots were written by nursing pioneer Florence Nightingale,34,35 who invented pie charts to illustrate the causes of deaths in hospitals. The next historical root is Warren and Brandeis'36 article focused on the right to privacy. This article became popular in the emerging discussions about patient rights to privacy in the information age.48 Shannon's mathematical theory on communication37 is the next and last historical root in the “little science period.” This work set the foundation for development of information and communication technologies and was also used to develop knowledge regarding improving communications between nurses, patients, health professionals, and computers.49
The first historical root of the big science period was the Dombal et al38 article vis-à-vis the accuracy of real-time human and computer-aided diagnosis. The authors discovered that some cases of computer-aided diagnosis might have had practical value. The article influenced the development of computer-supported tools in clinical reasoning and decision making in medicine and nursing.50 Ajzen and Fishbein's39 book on understanding social behavior and an article by Davis41 were the historical roots that become popular when analyzing and predicting the behavior of health professionals and patients' technology acceptance.51–53 Most of the historical roots from late 1980s until the beginning of the new millennium were associated with nursing informatics education, competencies, and skills.40,43–45 Rogers'42 seminal work on the Diffusion of Innovation theory was another historical root from this period. This theory proved important in research related to nurses' adoption of information technology tools.54 Koppel's work on the analysis of the role of computerized physician order entry systems in facilitating medication errors presented another historical root. This article had a significant influence on nursing informatics research related to patient safety55 and nurses' acceptance of clinical information systems.56 The last two historical roots,46,47 which were both review articles, analyzed impact of health information technology on quality and efficiency and influenced various facets of nursing informatics research and use.57Table 1 outlines the specific work, author, year of publication, and the form of identification within this study, while Table 2 highlights the evolution of themes in the field among the three periods identified in this study. In the period until 2004, nursing informatics research was still closely connected to the research in medical informatics and consequently to clinical decision making. However, nursing informatics began to be introduced into the nursing curricula, and specific nursing informatics–related terminology was developed. In the period 2005-2014, the nursing terminology was further developed and started to be employed in diagnosis and patient records. Nursing informatics has become a profession, and consequently nursing informatics professional culture and nursing informatics competency have become important themes in research. Interoperability, user acceptance, and biomedical informatics themes became a subject of study in the scope of nursing informatics. In the recent period, nursing informatics has become strongly involved in eHealth research and regarded as an important part of the advancement of nursing science. Nursing informatics education and competency research have become even more intensive. Nursing informatics also followed the important trends in information technology and health research, and thus big data and data integration, user-centered medication, and social media have been extensively studied.
Evolution of Topics and Problems Solved by Nursing Informatics
Before 1997, the most popular topics were medical informatics, diagnosis, and medical informatics education. Between 1997 and 2000, the focus shifted to nursing informatics, education, patient records, and terminology. Between 2000 and 2002, imaging, informatics competency, nursing informatics, bioinformatics, classification, and health information became popular. Telemedicine, shifting paradigms, and the Internet became important during the 2003–2008 period, followed by education, skill, competency, and patient record in the period 2009–2011. Health information technology and informatics competence became popular after that. Big data, interoperability, e-health, and innovation gained importance around 2016, followed by competency, hospitalization, data integration, and data science in 2017, and coordination, mobile applications (app), medication, simulation, and usefulness after 2017.
The health problems addressed by nursing informatics are compiled in Table 3. Before 1996, nursing informatics was primarily used to support diagnosis. In the next decade, it was used to improve patient outcomes and patient safety. In the short period 2007 and 2008, nursing informatics was employed to help patients with depression and older adults. From 2009 to 2011, its use spread to care of patients with chronic obstructive pulmonary disease and cancer, midwifery, and disaster management. During the period 2011–2014, nursing informatics began to support public health problems and care for patients who were overweight and obese. In 2015 to 2016, nursing informatics became involved in telehealth, primary care, home care, and care of disabled persons and stroke patients. In the recent period, nursing informatics began to address problems with management of nutrition, diabetes, and medications.
Nightingale has been credited as the pioneer of nursing informatics in historical reviews by Saba1 and Ozbolt and Saba11 due to her proposal to establish a statistical department in the Army. She, like nursing informaticists of today, used data tools to manage patient care. This study verified that Florence Nightingale authored the first scientific work and documentation with her use of data visualizations such as pie charts and invention of box plots.
In the remaining period of the “little science” epoch, nursing informatics learned from law and mathematical sciences. It is interesting to note that the computer science pioneer Allan Turing's articles and early articles on cybernetics were not found among the nursing informatics historical roots. The historical roots analysis revealed that the “big science” period of nursing informatics started in the 1970s, which is congruent with Saba's1 findings. The analysis of the dynamic of literature production revealed that the linear growth in production started in 1983 when CIN: Computers, Informatics, Nursing (formerly known as Computers in Nursing) began publication, a year after the IMIA Nursing Informatics Work Group successfully implemented its first open forum on the Impact of Computers in Nursing.1 Logarithmic growth began in 1992 after some important events in the United States, like the introduction of nursing informatics graduate programs at the University of Maryland and the University of Utah in 1989, establishment of the American Medical Informatics Association in 1990, and the recognition of nursing informatics as a nursing specialty by the American Nurses Association in 1992.
Historical research is important. In her review, Saba1 made some predictions about the development of nursing informatics in the twenty-first century. She predicted the emergence of mobile applications, wireless health technology, and telehealth, which was validated by this study. By understanding not only the past, but also the response to it, insight into the future can be gained.
In the last 50 years, nursing informatics has been rapidly advancing in both popularity and relevance, so it is no wonder that much is already known about the history. The history of knowledge development in nursing might offer nurses insight related to growth and evolution to influence the everyday practice settings58 and to improve the understanding of societal and technological forces, which challenge their profession.59
The study revealed that the field of nursing informatics has sought to respond to global health concerns. Additionally, it is evident that through intensive development, nursing informatics has become an independent research area with an influence on nursing advancements in general (Table 3). Furthermore, it is apparent through this analysis that nursing informatics has influenced other disciplines.
In the study of historical bibliometrics tools, specifically RPYS and bibliometric mapping were used to identify 15 historical roots, main themes researched in the three sequential periods. Additionally, the evolution of main topics and health problems being addressed by nursing informatics were explored.
This study offered an in-depth look at nursing informatics literature, using a systematic approach to identify historical roots and analyze the evolution of topics and themes in order to gain more information about knowledge development in nursing informatics. The results and analysis illuminated the impact of specific foundational and core scholarly works offering insight into the genesis and sustainment of particular bodies of literature in the field of informatics. The documentation of this impact has the prospect of making connections between the problem, research, and the application of findings to the clinical setting.
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