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Nurs Outlook xxx (2016) 1e13

www.nursingoutlook.org

Big data science: A literature review of nursing research

exemplars
Bonnie L. Westra, PhD, RN, FAAN, FACMIa,*, Martha Sylvia, PhD, MBA, RNb,
Elizabeth F. Weinfurter, MLISc, Lisiane Pruinelli, PhD, RNa, Jung In Park, PhD, RNa,
Dianna Dodd, MSN, RN, RN-BC, CCMd, Gail M. Keenan, PhD, RN, FAANe,
Patricia Senk, PhD, RNf, Rachel L. Richesson, PhD, MS, MPH, FACMIg,
Vicki Baukner, MS, RNh, Christopher Cruz, BS, RNi, Grace Gao, DNP, RNa,
Luann Whittenburg, PhD, RN BC, FHIMSS, FAANj,
Connie W. Delaney, PhD, RN, FAAN, FACMIa
a
School of Nursing, University of Minnesota, Minneapolis, MN
b
College of Nursing, Medical University of South Carolina, Charleston, SC
c
Health Sciences Libraries, University of Minnesota, Minneapolis, MN
d
Cerner Corporation, Kansas City, MO
e
University of Florida College of Nursing, Gainesville, FL
f
The College of St. Scholastica, Duluth, MN
g
Duke University School of Nursing, Durham, NC
h
Ridgeview Medical Center, Waconia, MN
i
Kaiser Permanente, Oakland, CA
j
MediComp Systems, Alexandria, VA

article info abstract

Article history: Background: Big data and cutting-edge analytic methods in nursing research
Received 4 June 2016 challenge nurse scientists to extend the data sources and analytic methods used
Revised 3 November 2016 for discovering and translating knowledge.
Accepted 21 November 2016 Purpose: The purpose of this study was to identify, analyze, and synthesize exemplars
of big data nursing research applied to practice and disseminated in key nursing
informatics, general biomedical informatics, and nursing research journals.
Keywords:
Methods: A literature review of studies published between 2009 and 2015. There
Big data
were 650 journal articles identified in 17 key nursing informatics, general
Data science
biomedical informatics, and nursing research journals in the Web of Science
Nursing informatics
database. After screening for inclusion and exclusion criteria, 17 studies published
Nursing research
in 18 articles were identified as big data nursing research applied to practice.
Nurse scientist
Discussion: Nurses clearly are beginning to conduct big data research applied to
practice. These studies represent multiple data sources and settings. Although
numerous analytic methods were used, the fundamental issue remains to define
the types of analyses consistent with big data analytic methods.
Conclusion: There are needs to increase the visibility of big data and data science
research conducted by nurse scientists, further examine the use of state of the
science in data analytics, and continue to expand the availability and use of a

* Corresponding author: Bonnie L. Westra, School of Nursing, University of Minnesota, 308 Harvard St. SE, WDH 5-140, Minneapolis, MN
55434.
E-mail address: westr006@umn.edu (B.L. Westra).
0029-6554/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.outlook.2016.11.021
2 Nurs Outlook xxx (2016) 1e13

variety of scientific, governmental, and industry data resources. A major

implication of this literature review is whether nursing faculty and preparation
of future scientists (PhD programs) are prepared for big data and data science.
Cite this article: Westra, B. L., Sylvia, M., Weinfurter, E. F., Pruinelli, L., Park, J. I., Dodd, D., Keenan, G. M.,
Senk, P., Richesson, R. L., Baukner, V., Cruz, C., Gao, G., Whittenburg, L., & Delaney, C. W. (2016, -). Big
data science: A literature review of nursing research exemplars. Nursing Outlook, -(-), 1-13. http://
dx.doi.org/10.1016/j.outlook.2016.11.021.

Background the quadruple aim of better health, improved patient

The era of big data and cutting-edge analytic methods in
research and clinical scholarship challenges nurse sci-
entists to extend the data sources and analytic methods
used for discovering and translating knowledge to
improve care quality and safety, lower costs, and
address provider satisfaction. Big data are described
most often with the five Vsdvolume, velocity, variety,
veracity, and value. The first three are the most com-
mon characteristics of big data (Brennan & Bakken,
2015; Gandomi & Haider, 2015; Kitchin, 2014; Marr,
2015). Volume refers to the magnitude of the data,
whereas velocity addresses the speed at which data are
generated, translated into research or practice, and
analyzed. Variety includes the availability and use of
multiple data sources and the structural heterogeneity
of the data types. One example of heterogeneity is the
integration of electronic health record (EHR) data com-
bined with death index data, genomics or imaging data,
social media, and personal app data. Veracity addresses
the characteristics of quality in that data are often
noisy, messy, and contain errors. Although issues of
data uncertainty result, data quality methods, tools,
and analytic methods can be used to reduce uncer-
tainty. Finally, value is defined as the ability to obtain
insights from the data and repurpose data for multiple
uses. The “big data” term represents large, complex data
sets that require new ways of thinking, novel analytics,
new team science members, and redesigning the core
constructs of conducting science as depicted in Figure 1.
Digital data are ubiquitous, making it possible to
amass big data to discover new knowledge and achieve
Figure 1 e Big data and data science nursing
research model.
experiences, reduced costs, and improved satisfaction
of providers (Bodenheimer & Sinsky, 2014). Boyd and
Crawford note that “Big Data reframes key questions
about the constitution of knowledge, the processes of
research, how we should engage with information, and
the nature and the categorization of reality .. Big Data
stakes out new terrains of objects, methods of
knowing, and definitions of social life” (p. 665). Kitchin
(2014) further asserts that a new epistemological
approach is needed to make sense in the world in
which new data analytics can lead to new insights
“born from the data” rather than testing theory.
We have moved into the fourth Paradigm of Research
(Hey, Tansley, & Tolle, 2009), in which patterns in data
lead to hypotheses for knowledge discovery, going
beyond hypothesis driving data collection. Discovering
patterns requires machine learning techniques that can
handle large complex data sets to create predictive
models for outcomes (Obermeyer & Emanuel, 2016).
Examples of big data methods or new data analytics
include both multivariate statistics such as logistic
regression and contemporary methods such as social
network analysis, natural language processing, data
mining, and machine learning techniques.
The National Institute of Nursing Research (NINR),
in its 2016 strategic plan, emphasizes the importance
of technology and its influence on nursing science
(NINR, 2016). Specific examples are mentioned in the
plan such as studying sensor technology to support
people safely remaining in their homes, electronic
health record data to identify high-risk patients for
hospital readmissions, and computational science for
tracking patients across the health continuum through
linked EHR data. Digital data are increasing in impor-
tance for science, and the methods to analyze such
data require new data analytics.
Insights and expertise from an interdisciplinary
team are needed to discover meaningful knowledge
from todays’ large, complex data sets (big data). Data
analysts with a strong knowledge of databases and
data dictionaries are needed to query the data and
determine data elements available and the best one(s)
to use. Data engineers often need to build a database
platform that can store multiple forms (variety) of data
that may include structured data, text, audio, and
video. Often the data need to be processed in real time
as it streams from various physiologic sensors or from
social media sites. Data scientists collaborate with data
engineers to merge large data files and preprocess the
data to harmonize it and eliminate redundancies,
 Nurs Outlook xxx (2016) 1e13
manage data gaps, and reduce errors. Like biostatistics,
computer science contributes a deep understanding of
mathematics and probabilistic and computational
power needed to manage and analyze large amounts of
data. Domain experts (nurse scientists) work closely
with data scientists and analysts to identify key factors
for analysis, reduce dimensionality, model the data,
and interpret the results.
“Biomedical informatics is the interdisciplinary,
scientific field that studies and pursues the effective
uses of biomedical data, information, and knowledge
for scientific inquiry, problem solving, and decision
making, motivated by efforts to improve human
health” (American Medical Informatics Association,
2016). Nursing informatics, specifically, is essential to
team science serving as the translator between domain
knowledge and computer science with the multifac-
eted connections of health conditions and its related
factors. Nurse scientists lead in important roles in the
interdisciplinary teams by providing clinical knowl-
edge and detecting meaningful signals from research
to advance health science.
Although working with large data sets and inter-
professional teams is not new for nurse scientists, it is
unknown if these nurse scientists are using advanced
and newer analytics to discover new knowledge,
contribute to the emerging precision medicine initia-
tive, and achieve the quadruple aim. Precision medi-
cine focuses on targeting treatment to individuals
based on genomics, individual patient characteristics,
environment, and lifestyle variables (National
Institutes of Health, 2015). Nursing science can make
use of big data to enhance nursing care that is tailored
to patients’ individual needs. The NINR supports nurse
scientists integrating big data into nursing research to
develop personalized care for preventing and man-
aging illness. It is imperative that nurse scientists
engage in big data and interdisciplinary research teams
throughout the process of identifying and using
methods of discovery to dissemination of findings.
Visibility in nursing research and interdisciplinary
informatics journals position nurse scientists to be
readily identifiable as innovators in academic nursing,
selected as reviewers on national big data and precision
medicine research peer-review panels, and recognized
as decision makers in health policy groups. The pur-
pose of this literature review was to identify, analyze,
and synthesize exemplars of big data nursing research
applied to practice and disseminated in key nursing
informatics, general biomedical informatics, and
nursing research journals.
Methods
Article Retrieval
A literature review was conducted to identify exem-
plars of big data nursing research applied to practice
3
and disseminated in key informatics and nursing
research journals and general biomedical informatics
journals. An exemplar indicates that the type of
research is one that advances the science by focusing
on more complex or cutting-edge methods of analyzing
big data. The following inclusion and exclusion criteria
were used in the literature search and subsequent
analysis of the studies retrieved. Inclusion criteria
included the following:
1. One of the authors must be a nurse to be considered
nursing research (Kim, Ohno-Machado, Oh, & Jiang,
2014).
2. Research is published in one of the peer-reviewed
journals listed in the search strategy (Kim et al.,
2014).
3. The focus is on nursing practice or systems that
affect nursing. Nursing practice is defined as
nursing care, patient conditions important to
nurses, and/or systems in which nurses work.
4. Data resources must be digital. Data science ad-
dresses the use of digital data according to the Na-
tional Consortium on Data Science (Ahalt et al., 2013).
5. Although inferential analysis can be used for big
data research (Wang & Krishnan, 2014), this litera-
ture search focuses on multivariate analysis or
contemporary methods of analyzing big data that
move the science forward.
6. Evidence of at least one big data characteristic:
volume in sample size or data points collected,
velocity of data, and variety in data format is
present.
7. Studies are published January 2009 through
December 2015.
Exclusion criteria were the following:
1. Designs that are qualitative, case studies, quality
improvement, surveys, or usability studies.
2. Analysis that is descriptive, univariate, or bivariate
only.
3. Research that focuses on teaching, learning, or
informatics competencies.
Search strategies were developed to identify articles
that met the criteria; however, a manual review
(described later) was conducted to further determine if
the studies met inclusion and exclusion criteria.
The literature search was designed and conducted by
a master’s prepared librarian with more than 15 years of
experience working with students, faculty, and staff
affiliated with the university’s Academic Health Center.
The search methodology was similar to that reported by
Kim et al. (2014) for review of nursing informatics
research. Kim et al. (2014) selected 13 key nursing infor-
matics, general biomedical informatics, and nursing
research journals and identified relevant studies pub-
lished from 2009 through 2013 in these journals using the
Web of Science database. For the current review, the
same journals selected by Kim et al. (2014) were used,
4 Nurs Outlook xxx (2016) 1e13
and four additional journals were included where
nursing big data articles were likely to be published.
These 17 journals were searched using the Web of Sci-
ence database on February 23, 2016. Results were limited
to publication dates from 2009 through 2015. This date
range defines the beginning of a new era for digital data
available in electronic health records through the time
frame when the literature search was initiated.
Three unique search approaches, each optimized
for the characteristics of the discipline, were
employed for each category of journals: nursing
informatics, general biomedical informatics, and
nursing research. For the nursing informatics journal
category, one publication was included (Computers
Informatics Nursing). All articles from this journal were
retrieved. For the general biomedical informatics
journals, eight publications were included (Journal of
Medical Internet Research, Journal of the American Medical
Informatics Association, Medical Decision Making, Interna-
tional Journal of Medical Informatics, Journal of Biomedical
Informatics, BMC Medical Informatics and Decision Making,
Methods of Information in Medicine, and Applied Clinical
Informatics). Because these journals are interdisci-
plinary, all journals in the general biomedical infor-
matics group were searched to retrieve articles listing
a nursing affiliation (school, department, college,
center, etc.) in the author affiliation field. For the
Figure 2 e Literature search results.
nursing research journals, eight publications were
included: International Journal of Nursing Studies, Journal
of Advanced Nursing, Nursing Research, Journal of Nursing
Scholarship, Nursing Outlook, Journal of Nursing Admin-
istration, Western Journal of Nursing Research, and
Research in Nursing and Health.
Journals in the nursing research group were
searched to retrieve broad big data research concepts
using the terms (“machine learning” OR “health infor-
mation technolog*” OR “data mining” OR “clinical
information” OR “health information exchange*” OR
“data warehous*” OR informatics) in the title, abstract,
or keywords. These terms were chosen by the team
after an initial broad general review of informatics
research articles to determine the most relevant key-
words used by any discipline conducting big data/data
science research. The combined results from all jour-
nal groups were then searched to exclude articles with
the words (usability OR education OR student* OR
learn* OR competenc*) in the title. We eliminated
usability as we did not find these types of big data
studies that apply to nursing practice or systems that
affect nursing. The final combined results were limited
to “article” publication type only, which excluded re-
views, editorial material, proceedings papers, correc-
tions, and letters. A total of 650 citations were retrieved
for further screening (see Figure 2).
 Nurs Outlook xxx (2016) 1e13
Analysis Method of Articles
The purpose of this literature review was to identify,
analyze, and synthesize exemplars of big data nursing
research applied to practice and disseminated in key
nursing informatics, general biomedical informatics,
and nursing research journals. Whereas the selection
of studies was based on the method of Kim et al. (2014),
the process of analyzing studies was based on one of
the methods noted in the typology of reviews by Grant
and Booth (2009). Fourteen types of reviews or methods
of analyzing the literature were described by Grant and
Booth (2009) as follows: critical review, literature
review, mapping review/systematic map, meta-
analysis, mixed studies review/mixed methods
review, overview, qualitative systematic review/quali-
tative evidence synthesis, rapid review, scoping
review, state-of-the-art review, systematic review,
systematic search and review, systematized review,
and umbrella review. The “literature review” method is
“an examination of recent or current literature [that]
can cover a wide range of subjects at various levels of
completeness and comprehensiveness, and may
include research findings. A literature review may or
may not include comprehensive searching, and may or
may not include quality assessment. [The synthesis is]
typically narrative [and the analysis] may be chrono-
logical, conceptual, thematic, etc.” (Grant & Booth,
2009). The current work fits the literature review ty-
pology of Grant and Booth (2009). A systematic litera-
ture search was conducted with selected journals.
Inclusion and exclusion criteria were applied. A quality
assessment of studies was not conducted. A narrative
format was used for synthesizing results.
The articles were reviewed using the following
process. The search strategy filtered out many articles
for consistency with the inclusion and exclusion
criteria for this literature review; however, further
screening of the abstract (or article when necessary)
was manually conducted by two nurses for each study.
An evaluation form was created in an Excel spread-
sheet to screen each article for consistency with the
following inclusion criteria: one of the authors must be
a nurse, the focus is on practice, study meets exclusion
criteria for study designs, data source is digital, the
analysis is multivariate or contemporary methods, and
the data are consistent with big data characteristics of
large volume, variety, or velocity. A percent agreement
was determined between the two reviewers whether a
study met the criteria for nursing big data research as
defined in this literature review.
Results
There were 650 articles identified from the literature
search that were further screened for final consider-
ation as exemplars of nursing big data research
consistent with the inclusion and exclusion criteria.
5
Each article was reviewed by two of the authors, and
the percent agreement ranged from 82.1% to 100% for
each group. Reviewers were then asked to resolve
disagreements if less than 95%, those greater than 95%
were reviewed by the primary author. This resulted in a
percent agreement ranging from 92% to 100%; studies
with disagreement were retained for the next level of
evaluation. A screening of the resulting list of 28
studies was conducted using the same instructions in
the first review by five of the authors with a final
identification of 18 articles representing 17 studies is
noted in Table 1.
Purposes
The 18 articles retained represented 17 studiesd2
articles represent 2 parts of the same study (Buis et al.,
2013a; Buis et al., 2013b). Examination of studies
revealed three overarching purposes for carrying out
each studydknowledge discovery, prediction, and
evaluation. Six studies were considered to be knowl-
edge discovery because they sought to understand the
capability of big data to discover new meaning, five
studies examined predictive factors of process and
outcome measures, and six studies evaluated the
impact of technical or nursing interventions on patient
outcomes.
The knowledge discovery studies included identi-
fying factors, associations, or patterns related to pa-
tient outcomes using methods such as data mining and
natural language processing. The purposes of the
studies about prediction included development and
improvement of an algorithm or a tool to predict risk
factors or patterns for patient outcomes. Evaluation
studies included development, assessment, and eval-
uation of a new framework or tools for patient out-
comes such as decision support system, care
coordination, or internet portal using large data sets
and big data analysis method.
Settings
Settings for 10 of the 17 studies were acute care or
inpatient, 2 were ambulatory care based, 2 were com-
munity based (following individuals across settings of
care), 2 were in home health care, and 1 was in a public
health department.
Data Sources
The primary source of data was the EHR (n ¼ 14). In
some instances, the data were directly from the EHR
and in other cases, the clinical data were integrated
into a database or data warehouse. Two studies used a
variety of data sources integrated with EHRs. For
instance, one study integrated registration, scheduling,
and billing data with EHR data (Merrill, Sheehan,
Carley, & Stetson, 2015), whereas another study inte-
grated data from the hospital credentialing system,
state provider registration system, and the EHR (Cho
 6
Table 1. e Results of Nursing Big Data Science Exemplar Studies

Stated Purpose Setting Source of Data Design/Analytic Sample Big Data Nurse as
Collection Techniques Category Author
Knowledge discovery: to identify critical Acute care: Taiwanese Database, Web-based Retrospective cohort 3,324 pressure ulcer Volume First
factors related to patient falls through regional 1,000-bed incident reporting design/data mining incidents, 725 patient
the application of data mining to teaching hospital system artificial neural fall incidents
available data through a Web-based network analysis and
hospital reporting system (Lee et al., multivariate stepwise
2011) logistic regression
Knowledge discovery: to present Acute care: three labor Enterprise data Retrospective cohort 686.402 L&D Volume Second
methods for identifying and analyzing and delivery units warehouse containing design/logistic documentation events variety
associations among nursing care affiliated with one specialty EHR for labor regression (linear) and associated with the set
processes, patient attributes, and health system and delivery survival analysis of 1,093 patients
patient outcomes using unit-level and
patient-level representations of care

Nurs Outlook xxx (2016) 1e13

about labor and delivery derived from
computerized nursing documentation
(Hall et al., 2009)
Knowledge discovery: to explore the Acute care: oncology EHR nursing notes Retrospective cohort 553 oncology nursing Volume First
ability of NLP for capturing nursing unit in an academic design/natural notes for 22 oncology variety
concepts to describe most frequent institution in New language processing patients
signs and symptoms and York City
interventions related to
chemotherapy side-effects and pain
management; to determine feasibility
to extract patient safety and outcomes
only available in nursing notes and
structure the data for analysis (Hyun
et al., 2009)
Knowledge discovery: to determine the Acute care: large health Clinical and Retrospective cohort 4,308 patients with CHF Volume First
feasibility of using network analysis to system that includes administrative data study/network variety
explore patterns of service delivery for inpatient and sets from the EHR, analysis using
patients with congestive heart failure ambulatory care registration, CoUsage and
who transit between services and scheduling, and Transition Networks
settings (Merrill et al., 2015) administrative billing
system
Knowledge discovery: to investigate Public health: a public Database, research Retrospective cohort 726 high-risk mothers Volume First
problem stabilization, a metric for health department study/KaplaneMeier who received 50,360
problem improvement during home curves interventions
visiting services for high-risk mothers
(Monsen et al., 2011)
(continued on next page)
 Table 1. e (Continued )
Stated Purpose Setting Source of Data Design/Analytic Sample Big Data Nurse as
Collection Techniques Category Author
Knowledge discovery: to utilize data- Acute care: 1,000-bed Database, Web-based Data mining exploration 3,324 cases of pressure Volume First
mining techniques as a means of Taiwanese regional incident reporting using neural ulcers
identifying risk factors related to teaching hospital system networks, support
different stages of pressure ulcers to vector machines,
demonstrate how this means of classification and
analysis might be used as a vehicle to regression trees,
guide improved care quality (Lee et al., random forests, and
2012) boosted trees,
followed by
multivariate stepwise
logistic regression
Prediction: To develop a measure to Home health: patient Integration of multiple Retrospective cohort 1,643 home care patient Volume First
predict risk of hospitalization among episodes from 14 data types from study/generalized episodes variety

Nurs Outlook xxx (2016) 1e13

home care patients, the small- to mid-sized multiple home health linear regression and
hospitalization risk score, and Medicare-certified EHRs ROCs
compare it with an existing severity of home care agencies
illness measure, the Charlson index of located in the mid-
comorbidity (Monsen et al., 2012) west and one on the
east coast
Prediction: to assess the effect of Ambulatory: primary Prescription logs from Cross-sectional 478 providers Volume First
provider-level characteristics on care practices an EHR observational study/ (physicians and nurse variety
variation in medication prescribing affiliated with two Hospital credentialing univariate analysis practitioners), 20 or velocity
patterns and the relationship of these teaching hospitals center, State provider and generalized linear more alerts per
patterns relative to the rates of alerts registration system regression model with provider
and overriding alerts (Cho et al., 2015) maximum likelihood
estimates
Prediction: to determine the degree to Acute care: university Nursing notes from the Retrospective cohort 23,528 electronic patient Volume First
which the clinical information in the hospital in Finland EHR and heart patient study/linguistic records, 132,053 data variety
electronic patient record can be used acuity from an acuity preprocessing, vector- points
to predict their Oulu patient system space text modeling,
classification acuity scores the next and regularized least-
day (Kontio et al., 2014) squares regression
Prediction: to compare data mining Acute care: military Military Nursing Retrospective 1,653 patients medical- Volume Last
models to identify clinically relevant hospitals in the United Outcomes Database observational study/ surgical, critical care,
factors, beyond the Braden Scale, States data mining, and step-down units
associated with pressure ulcers and to regression, decision
accurately predict pressure ulcer trees, random forests,
prevalence (Raju et al., 2015) multiple adaptive
regression splines
(continued on next page)

7
 8
Table 1. e (Continued )
Stated Purpose Setting Source of Data Design/Analytic Sample Big Data Nurse as
Collection Techniques Category Author
Prediction: to improve the algorithm for Home health: 15 Integration of multiple Retrospective 911 home health Volume Last
predicting elderly patients’ risks for Medicare-certified data types from observational study/ patients variety
readmission by optimizing the home health care multiple home health ROC analysis and
underlying criteria within the agencies EHRs logistic regression
algorithm and determining the
optimal cut points for the high-risk
medication regimen (Olson, Dierich,
Adam, & Westra, 2014a)
Evaluation: to examine the influence of Acute care: nine Electronic Comparative study/data 840 pressure ulcer Volume First
nurse continuity on the prevention of medicalesurgical and documentation tool mining cluster episodes of care variety
hospital acquired pressure ulcers critical care units in HANDS analysis, logistic
(Stifter et al., 2015) two large regression
communities, 1

Nurs Outlook xxx (2016) 1e13

university, and small
community hospital
Evaluation: to develop and assess the Acute care: large, urban, EHR integrated into a Before and after 1,214 surgical ICU Volume First
impact of a decision support not-for-profit, clinical data comparative study/ patients variety
intervention to predict hospital university-affiliated repository logistic regression and velocity
acquired pressure ulcers on the teaching hospital in Poisson regression
prevalence of ulcers and length of stay Seoul model
in an ICU and on the user adoption
rate and attitudes (Cho, Park, Kim,
Lee, & Bates, 2013)
Evaluation: to use the RE-AIM Community: three Multiple data systems Prospective evaluation/ 1,838/5,570 participants Volume Last
framework to document txt4health Beacon communities: multiple regression enrolled in text variety
efficacy, reach, and adoption. A text Southeast Michigan, message program
message program was used to raise Greater Cincinnati,
Type 2 diabetes risk awareness and New Orleans, LA
promote behavior change (Buis et al.,
2013a; Buis et al., 2013b)
Evaluation: to describe the types of Ambulatory care: Data warehouse that Retrospective 5,963 patient portal Volume First
diabetes patients who utilize the academic health includes data from observational study, users variety
patient-provider Internet portal and system EHR and patient portal linear regression
explore any preliminary differences in
patient outcomes (Shaw & Ferranti,
2011)
Evaluation: to examine the effect of the Acute care: three Discharge Decision Quasi-experimental, 3,005 assessments for Volume First
Discharge Decision Support System hospitals in a large Support System (D2S2) two-phase study newly admitted variety
on 30- and 60-day readmissions urban, academic software integrated (control and hospital patients
(Bowles et al., 2015) health center into an EHR experimental phases)/
regression, Cox
proportional hazards,
KaplaneMeier product
limit curve
(continued on next page)
 Nurs Outlook xxx (2016) 1e13 9

et al., 2015). Two studies obtained data from a Web-

Nurse as

Note. AIP, aging in place; EHR, electronic health record; HANDS, Hands on Automated Nursing Data System; HHC, home health care; ICU, intensive care unit; NLP, natural
Author based reporting system. In another study, a nursing
outcome database was used.
First
Category
Big Data

Analysis
variety
Volume

The majority of studies (n ¼ 10) used some type of

regression analysis either alone or in combination with
management notes for

other methods, for example, survival analysis, Cox

271 patients with AIP
care compared with

proportional hazard models, data mining, and

692 receiving HHC

machine learning. Other analytic techniques included

Sample

clustering, decision trees, KaplaneMeier curves, natu-

ral language processing (including linguistic pre-
12,235 case

processing), network analysis, neural network

analysis, random forests, receiver-operating curves,
support vector machines, survival analysis, and vector-
spaced text modeling.
then t-tests to contrast
create ontology with
language processing
to extract concepts,

weighting for dose,

Design/Analytic

Retrospective cohort
Techniques

Meeting Big Data Requirements

design/natural

Each of the studies met at least one of the big data

characteristics. Volume was defined by the sample size
that was the unit of analysis or the number of data
points collected on the sample. Examples of large
sample sizes include 4,308 patients with CHF, 5,963
portal users, or, 23,528 electronic patient records. Ex-
EHR case management

amples of large numbers of data points include 12,235

Source of Data

nursing notes, 50,360 interventions, or 20 or more

Collection

alerts for 478 providers. Variety indicated either two or

more data sources or types of data, that is, adminis-
trative and clinical or structured and unstructured
notes

data. For example, administrative claims data were

combined with clinical data to evaluate patterns of
care across settings for CHF patients, and EHR in
combination with patient portal data were used to
explore differences in diabetic patient outcomes for
ambulatory, HHC

portal users.
Setting

Studies were identified with the big data character-

istic of velocity if data points were accumulating in
Community:

language processing; ROC, receiver-operating curve.

very small time frames so that a minute or hour of time

produces an enormous amount of data points, for
example, alarms or alerts. For instance, one study
measured physician override rates for specific types of
alerts (Cho et al., 2015). All 17 studies used high volume
Evaluation: to create a domain-specific

data; 2 were considered high velocity and 12 used a

coordinators and HHC nurses when
ontology of care coordination using

compare specific care coordination

concepts extracted from notes and

suggest a method to quantify care

coordination (Popejoy et al., 2015)
natural language processing with

variety of data sources or types of data. Veracity and

activities used by AIP nurse care
weighted for dose of activity. To

community-dwelling adults and

value characteristics were not represented in the

selected studies.
coordinating care for older
Table 1. e (Continued )

Nurse Authorship
Stated Purpose

To be included in the study, one of the authors had to

be a nurse. All articles included at least one nurse as an
author. For 13 of the articles, nurses were first authors.
A nurse was last author in four publications and sec-
ond author in one publication.
10 Nurs Outlook xxx (2016) 1e13
Data Management Issues
Data management issues can be categorized as data
selection, preparation, and transformation analysis.
Selection begins with the data source as noted in
Table 1 and also includes selecting variables and
patients to address research questions. Rather than
using all available data, inclusion and exclusion
criteria are used to select subsets of observations.
Data sources noted in Table 1 required users to iden-
tify the variables of interest from a large pool of data.
In some cases, investigators selected variables based
on review of the literature; however, some variables
were eliminated due to missingness, duplication of
data, or events that were too small for analysis (Cho
et al., 2015). Other investigators that included a large
number of variables then used feature selection
methods to find variables significantly related to the
outcome before proceeding with further analysis (Lee,
Lin, Mills, & Kuo, 2012).
Data preparation for big data research has simi-
larities to traditional research, such as detection and
management of missingness and outliers. However,
the question of whether missing data occur at
random or if there is a pattern of missing data affects
whether the data can be imputed or if variables or
patients are eliminated from the analysis (Hall et al.,
2009; Lee et al., 2011; Monsen, Farri, McNaughton, &
Savik, 2011; Raju, Su, Patrician, Loan, & McCarthy,
2015). In one study, computation and imputation
techniques, such as random forest, were used to treat
missingness when data were not removed (Raju et al.,
2015). To address outliers, one method was the use of
standards scores, such as Z value or retention of data
within three standard deviations of the mean, to
transform and standardize data (Lee et al., 2011, 2012);
others excluded patients that were outliers (Hall et al.,
2009).
Transformations of the original data created new
variables in some studies. Algorithms were used to
combine medical diagnoses into the Charlson index of
comorbidity, transform Omaha system problems and
ratings into a hospital risk score to predict hospitali-
zation, or determine patterns of interventions to
represent problem stabilization (Monsen et al., 2011,
2012). Textual data were transformed using natural
language processing (NLP) into a numerical format for
analysis (Hyun, Johnson, & Bakken, 2009; Kontio et al.,
2014; Popejoy et al., 2015); however, NLP requires a set
of standard terms such as those from evidence-based
guidelines or terminologies to support the trans-
formations (Stifter et al., 2015). Olson, Dierich, and
Westra (2014b) automated mapping of medication
data to data standards and mapping of data
to instruments such as the Beers criteria and
Potentially Inappropriate Medications for predicting
rehospitalization.
Transformation is also used to summarize large
numbers of events or convert continuous or ordinal
data into categories. An example is the number of
patients per day per provider or episodes of care per
patient; an average is one method to summarize large
numbers of events (Cho et al., 2015; Monsen et al.,
2011). Another example is transforming continuous
data into classes or categories such as age, vital signs,
fall risk scores, or rank of a medical school (Cho et al.,
2015; Lee et al., 2011). Domain expertise and review
of the literature are essential to determine how
to best transform these variables for meaningful
results.
Discussion
The era of big data and cutting-edge analytic
methods in nursing research and clinical scholarship
challenge nurse scientists to extend the data sources
and analytic methods used for discovering and
translating knowledge to improve care quality and
safety, lower costs, and address provider satisfaction.
Are nursing scientists and is nursing science
addressing big data and data science opportunities to
advance nursing knowledge? The purpose of this
review was to identify, analyze, and synthesize
exemplars of big data nursing research applied to
practice and disseminated in key informatics and
nursing research journals between 2009 and 2015.
Seventeen studies were identified. This literature
review confirmed that nursing scientists have
engaged in big data and data science.
Although this finding is promising, multiple chal-
lenges are clear. The majority of studies focused on
clinical practice, in a general sense; specificity in both
description of the practice environment as well as
more studies specifically addressing nursing clinical
practice are needed. There is an urgent need and op-
portunity to expand big data science in health promo-
tion, chronic care, symptom management, and
systems. How can nursing advance the big data science
opportunities across the care continuum, from home
health, to intensive care, to acute and chronic care for
children, adults, families, and communities? How can
big data science be extended to include health trajec-
tories? How can big data science be expanded to
include systems data, for example, the Nursing Man-
agement Minimum Data Set, to understand the
contextual impact on care management, outcomes,
costs, and patient satisfaction?
Although multiple data sources were used in the 17
studies, nursing science is clearly not accessing the
plethora of data resources available and applicable. Of
particular note was that only one study was found
related to public health (Monsen et al., 2011). Because
public health has long been noted for amassing large
data sets, this raises questions as well as opportunities.
Although numerous data sources were used in the
studies cited in this literature search, there was no
 Nurs Outlook xxx (2016) 1e13
evidence of data from sources such as clinic, urgent
care and school settings, administrative claims data
from a health plan/insurer perspective, or laboratory or
imaging data. Social media data are available and used
in other health-related studies; how does nursing
expand to include these data sources? Data originating
from wearable technologies is an additional area for
further big data research. Further, consideration of the
social determinants of health and molecular biology
combined with EHR data would empower nursing sci-
ence using big data to address the complexities of
health and nursing. Multiple networks supporting
access to data from a multitude of settings, sites, and
collaborating partners are available, for example,
Patient-Centered Outcomes Research Institute (PCORI)
and Clinical and Translational Science Awards
(CTSAs). Although PCORI and CTSAs report engage-
ment of nursing, no evidence of the use of these con-
sortia and data resources that are available within and
across consortia was present.
Although numerous analytic methods were
employed in the 17 studies, several issues emerged.
Most fundamental is the current definition of big data
analytic methods. This literature review excluded
descriptive and inferential statistics and included NLP,
social network analysis, regression, and data mining.
Often, medical ontologies are used with NLP to map
notes for further analyses of structured data. More
clarification and precise definition of data science an-
alytic methods are needed. Consideration of analysis of
unstructured data, analysis of multimodal data, and
network science approaches are areas for further
research. Power analyses, unconventional data designs
including optimization of relational data and partially
observed data, need to be explored.
More fundamental to this work is the question:
what are big data and data science and implications
for discovery? Is it just new methods? Is it just having
access to more data? NIH notes that “big data is more
than just very large data or a large number of data
sources” (National Institutes of Health, 2015). Data
science is an interdisciplinary field that focuses on
creating models that capture the underlying patterns
of complex systems and codifying models into work-
ing applications (Dhar, 2013; Leek, 2013). In contrast
but complimentary, big data focus on collection and
management of large amounts of varied data. This
field of study extends beyond a new method; it is the
emergence of the fourth paradigm of scienced
eScience (Hey et al., 2009). The emergence of this field
provides scholars with an opportunity for in-depth
discernment of Kurzweil’s (2006) concept of singular-
ity, a point at which the combination of human and
machine intelligence transcends the limits of a
human mind. Chatterjee further asserts that
“branches of science that were earlier thought to be
separate entities and self-contained in their own do-
mains are merging incessantly .The human brain is a
complex, adaptive and a self-organizing system. In-
telligence is an emergent property of this complex
11
networked structure . the human brain is a dissipa-
tive system, an entropy producing machine”
(Chatterjee, 2012, p. 578). The key challenge is deter-
mining how nursing scientists partner with the data
science field to transcend human intellectual
limitations.
Finally, another major implication of this literature
review is to ask whether nursing faculty and our
preparation of future scientists (PhD programs) are
prepared for big data and data science. What are the
implications for PhD curricula? What strategies can be
employed to prepare faculty and support PhD curric-
ular redesign? In addition to socialization of teams, this
field of inquiry requires a team composition that in-
cludes, for example, domain experts, nurse scientists,
data scientists, predictive modeling (epidemiology)
experts, data engineers, and data dictionary analysts,
among others. Do our current resources in academic
environments support large-scale computing?
Limitations
There are a number of limitations to this literature
review. First, additional nursing big data studies may
have been missed by limiting the journals and specific
key words searched for this review and the timeframe
selected. Given the difficulty in determining whether a
scientist/author is a nurse could have resulted in
missing additional nursing studies. Although it is
recognized that emerging new science is often first
reported in conference proceedings, this source of
dissemination was not part of the literature search.
The literature review also limited the types of analytics
to focus on stronger associations or causal analysis
using traditional statistical methods as well as cutting-
edge contemporary analyses. Inclusion of a broader
array of analytic methods would demonstrate the
increasing emphasis on use of big data for nursing
research.
Future Directions
The purpose of the literature review was to identify,
analyze, and synthesize exemplars of big data nursing
research applied to practice and disseminated in key
informatics and nursing research journals. Future
studies are needed to search additional journals,
include additional types of studies such as surveys,
and other analytic methods. Grant and Booth (2009)
identified 14 types of reviews, some of which eval-
uate the quality of the studies; this work remains to be
done. As an increasing number of nurse scientists
foray into big data and use of data science, there is a
need to continuously make this work visible in jour-
nals such as those included in the current literature
review. It is imperative that nurse scientists and
nursing research in big data science clearly explicate
the meaning and importance of the studies to nursing
practice. Finally, big data and data science invite our
12 Nurs Outlook xxx (2016) 1e13
science to reinvent itself within this emergent para-
digm shift.
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