NURSING TELEMACHUS

AND COMPUTERS

INTRODUCTION

The aims of this 'dialogue' are threefold. First, simply to explore through the minds and voices of two ancient characters, contemporary nursing informatics and telematics issues. Secondly, to test the viability of the dialogue as an alternative format to the usual academic paper. And thirdly, to introduce unfamiliar readers (students?) to 'the' master of the dialogue form - Plato.

Readers may (hopefully) be stimulated to seek out Plato's works, which are freely available in affordable paperback editions. 'The Last Days of Socrates' is recommended as a starting point. Plato captures in the dialogues the technique employed by Socrates, that still bears his name - 'Socratic questioning'.

As health professionals search for ways to reassert values amid unprecedented technical and social change, philosophy is once more on the agenda. This attempted 'dialogue' has two protagonists. Telemachus, who is in name from Homer's Odyssey and other Hellenic literature. The name appeals to me here due to the study of 'tele'-matics, a key branch of informatics research.

Epictetus (50-120A.D.) was a philosopher of the stoic school. Sometimes we find unexpected connections in things, as with Epictetus: nursing - health - ethics/values - philosophy - Enchiridion (Manual) health - how to live ones life - leadership - 3,000 drachmas paid for E.'s lamp after his death - Florence Nightingale - nursing!

Telemachus is a student of the Academy established by Aristotle, starting his third year of nurse training. Epictetus is staged as a professor, a member of the faculty for health. With apologies...

It is high summer. A beautiful morning waits to greet the citizens of Athens, but not all. Epictetus, his robes flowing is just about to leave the academy, when he spies a student.

EPICTETUS: My word Telemachus, what problem fastens you to the library's desks on such a fine day? Surely you know that body and mind need balanced proportions of sunlight, air, good food, wine and company?

TELEMACHUS: Yes Epictetus I recognize the good and beneficial things that I miss, but I have a complex problem, that I would be grateful to discuss with you?

E: Surely, and with pleasure, but not here. I fear we are already attracting disdain, come let us go outside....
This problem then - I assume it is connected with your current studies in caring for the people?

T: It is. The problem is caused by external forces. A machine not of war, although that must be a possibility someday, but a machine of the mind. A machine more powerful than the abacus and the Oracle at Delphi combined. You know of this I am sure?

E: Yes. And debated much about the capacity of these machines to "think" like men. T: The machine is called a 'computer'. They wish to use the machine to solve problems in nursing. Problems of resource management initially, with the promise of solutions to clinical problems with benefits for patient care too. In order to answer the questions, the problems must be described logically. The problem then is to capture what nursing is about?

E:Ah. If only you could capture this essence of nursing and bottle it. And what are your thoughts thus far Telemachus?

T: Well it seems to me that it is one thing to describe the angles and proportions of the squares of a triangle as our arithmeticians do so well. Or even to list the antidotes to snake bites; or balms for sunburn and chapped hands. But caring for people, this is a problem of another order.

E: Why do you find it so? No, do not look so surprised Telemachus. If you want my help I insist you consider the question. Let us humour each other.

T: Well, as you know, nursing seems so much a matter of administering good food, wine, sunshine, fresh air, and treatments in the correct proportions. We do X to achieve Y, but it is not so straight forward. After scratching the surface I am faced with complexity and cussedness. The managers, indeed our whole state is suddenly obsessed with information. An obsession beyond the weekly events at Delphi, as the machine processes data.

E: How does this cause a problem?

T: Nurses use data that is true. How many stab wounds, broken ribs, and bruises. How far a man should be able to march, how much water a woman is capable of carrying. Data - as in a number - is just a number when the context is removed, but nurses use information. Computers cannot handle information. It remains...

E: Please! Hold on a second, why not information?

T: Computers are designed to process a sequence of data. Although to us they process information, they are not designed for that task. You're still not convinced? Well, if they wanted a computer to - say, understand a scene, we humans have a distinct advantage. The programmer has to break up the scene into (data) elements for processing. But people can deal with patterns, integrating the data in the scene as a whole, without seemingly thinking about it. In reality I suppose we must, but there it is.

E: Mm, I see! Carry on then.

T: Where was I? Oh yes. The powers that be are uncertain of just how far they wish to code the activities of nursing, and I must add medical activities. The nurses resent their care being reduced to quantities like some Pythagorian exercise. Nursing is more than the sum of several numbers. So much information is lost. The clerks do not help. It's as if no one knows whether we should count the number of buckets, or the number of grains of sand in the buckets that we carry. As you know Epictetus health itself is very complex.

E: I see. So if I have heard and understood, you are saying that nursing is not just about quantity, the managers must decide how far to reduce nursing. To do this they must wrestle with our friend complexity. Perhaps we too, should indulge ourselves at this point? Please Telemachus - help me recover my knowledge of health matters.

T: How shall I do that?

E: If health is complex then there must be numerous ways to account for the complexity you find Telemachus. What do Plato and Socrates say on the matter?

T: Well, some aspects of health are given by the Gods, some by men themselves.

E: So do we have a choice in being a patient?

T: The answer must be yes and no. Yes, when a man's over indulgence leads to problems, as when he over eats or drinks to excess. And no, when the Gods intervene, affecting the quality of life of many people. Our saving thought, as Plato taught, is that we can lose our sight, go mad, lose a leg. But the Gods smile upon us as long as we retain our virtue. For an unjust man has truly lost everything.

E: So when does a person become a patient?

T: Well, I can call upon Aristotle for help.

E: Mm Telemachus, you realize the merits of the living are controversial, how does a contemporary help us?

T: Aristotle's four causes could be useful? Let me see, yes, in this instance they can be used as 'becauses.' First the material cause. Patients become patients by virtue of the substances they are made of. They break bones, cut their skin. Sadly some of us literally lose our minds. The formal cause can account for the way babies grow to adulthood and, if we are fortunate we gradually wither in old age and die. Sometimes development is arrested or interrupted in some way. Then there is the efficient cause, we become ill if we do not eat good food. A warm safe environment with exercise of mind and body, will push us towards a state of positive health. Finally Aristotle speaks of telos, the ultimate goal, or the teleological cause. Here humans and other creatures move relentlessly towards their mature state, usually to ensure propagation of the species.

E: I must admit that is a useful tool, to get at the 'what' of health. Since we are preoccupied in personalities, Telemachus, a further question. If health were personified Telemachus, who would health be?

T: Why, that is easy. No single person, indeed no person, as we think of at all. I would have to say that health would simultaneously be Hercules; Helen and Socrates.

E: Ah, good, well remembered Telemachus. So you are saying that if nothing else health is strength; beauty; and wisdom. You have paid attention, but let's get back on track. Why is health suddenly a concern of the senate then?

T: There is the health of our democracy. How health care can be financed. Health is also fitness to vote. A democracy cannot exist without its citizens. Furthermore, they must codify how we nurses care for people, so that the clerks can compute and process cost information. Despite the news from Marathon the counsel are checking the treasury. A prolonged campaign upsets the balance of demand and supply. Not least of the true citizens who can use a sword.

E: So you must not only reconcile the world of nursing and that of information, but politics too? My, if only Plato or Socrates were at hand. At this juncture it seems we need an example to wrestle with. Can you provide us with one?

T: I was afraid you would ask, but I shall try. A man breaks a bone in his lower leg, he can no longer walk for many weeks. His family must offer what support they can and try to do his work for him. At first glance it appears this problem is physical, but the man is affected in other ways. Not being able to go to work depresses him. He feels useless and becomes argumentative with family and friends. The physicians are subjected to his curses, why he is worse than old Xanthipe. He consults with one after another, seeking what - only the oracle knows. He can no longer freely wander to listen to the debates in the agora, partake in the baths, or games.

E: Yes, certainly, this would be so, but I fail to see where the problem is? Surely such a reaction is normal? A broken vine cannot carry the grapes. Have you never thrown a pot, or cursed those you love when your freedom is restricted for whatever reason?

T: Thrown a pot, yes - in more ways than one, but I leave the cursing to the players. If I am to code the activities undertaken both to describe the problem, and to make the man better where do I start? I can record many aspects, but these latter experiences of the man confound me. Perhaps the problem is intractable, of such a nature that it is best left alone. Nursing is not mathematics.

E: You disappointment me Telemachus. This is not like you. Surely your mentors will appreciate your efforts in understanding the problem even if you cannot solve it. Please answer me this - what is your course called? T: Nursing informatics. E: Expand each word for me, but do not think too deeply Telemachus. Quickly now, do not hesitate, while we find some shade.

T: Nursing is that discipline whose adherents care for people in need. Need in the sense that they cannot look after themselves. Using scientific knowledge and practical skills they help patients balance the humors of the body and mind. Informatics is the study and management of information, and the application of computing machinery in health care.

E: Is nursing a science as your definitions would suggest?

T: Yes, but also one of the caring arts.

E: One of the caring arts? Both an art and science then - intriguing to say the least.

T: There are those who "think nursing", their heads virtually in the clouds. Producing models of nursing, nursing theories...

E: Indeed! And I thought only philosophers nursed theories. Sorry Telemachus, pray continue.

T: Many lack insight into the things they teach, in a way far removed from the everyday problems of their discipline, like armchair astronomers. Others who practice do so with their heads in the sand, they do not know what their hands are doing, other than trying to follow the dictates of sun and stars. Apparently there is a new model in mental health. It uses the selenographic co-longitude of the sun on the moon.

E: Goodness. Why - that sounds very scientific. You must tell me more?

T: The sun affects the terminator apparently, although some of the terms are alien to me?

E: Well perhaps I can sum up this particular model for you. When you next assess someone Telemachus ask yourself - is it a full moon tonight?

T: Oh! I fear have been made a fool of!

E: Not at all, I won't tell a soul, but remember human activity is not just about terms, but how we use them. What of the other nurses?

T: The rest; well they do so heads bowed. Bowed in distrust and disillusionment. Yes, they try to manage change, looking left, looking right, one eye on the patient, one on the past, and one on future - which is obviously an impossible state of affairs. Those skilled in the caring arts are at risk of forgetting who they are.

E: Morale, aside Telemachus, tell me what is this art to you?

T: Art? I would say it is a both a skill to be developed, that is learned, and one a gift from the Gods. Passed from generation to generation.

E: The physicians and chemists are similar are they not? They have to learn skills, and their dexterity in handling the aches, breaks and stresses of bones young and old are born within them. So doctoring is both a science and an art? And nursing is the same?

T: No. I think not. There are similar features, a midwife must know of anatomy and physiology, but at a different level to the physician. Also the proportions of knowledge are different. The doctor is concerned with the herbs and abstinence that will cure an ailment. The nurse with the persons' response to the treatment. Am I making sense?

E: Yes, you are doing well, for someone who claims he has a problem.

T: I can best sum up the situation by observing that what aptitude is to the arithmeticians, so attitude is to the nurse. The desire to care must come first.

E: Once again well observed, the physicians still often lack in bedside manner. But this knowledge that nurses must use, tell me more?

T: But that I could!

E: Well tell me what makes it different from the medical arts?

T: The main thing must be the contact the nurse has with her charge.

E: And the consequence of this?

T: The two must get to know each other, even better than physician and patient. The nurse has constant care, the medic may visit occasionally. Unless of course a fall or kick from a horse has sent the patient to some realm of the Gods? Then the attention may be continuous, by both nurse and physician, at least initially.

E: So what does the nurse actually need to aid such constant contact with the patient? T: Patience, understanding, empathy, confidence, practice with proper training. E: What of knowledge?

T: That is the root of the problem.

E: And so you must find the branches. How they grow, how are they fed, how pliable to the wind and other elements. Knowledge disposes us to act in certain ways. Your personality in turn determines what information is deemed significant.

T: As ever, eloquently put mentor.

E: Tell me how are these caring arts delivered to a person in need?

T: If for example, they are semi-mobile, then supervision or assistance to transfer from a to b is a key task.

E: How do you decide that mobility is the problem?

T: Why - from the facts before my eyes? The patient's explanation of cause and effect. The fundamental thread from cues to inferences, from inferences to problems. It is true our eyes can deceive us, but there are no oars in water here.

E: So what name would you give to the process by which you derive the problems in need of caring.

T: Various terms are used - 'assessment' being the most common; 'information gathering'; 'evaluation' - there are several.

E: You mentioned evaluation. Is evaluation the same as assessment? T: No. At least not if the stages of problem solving are adhered to. E: And they are? T:Assessment; Planning; Intervention; and Evaluation. The four stages are reiterated with the problems identified in assessment, care planned in stage two, intervention in the third, with the outcome evaluated finally.

E: The assessment is repeated then?

T: No, not completely. Evaluation focuses on the problems initially identified. At first encounter the assessment is thorough, as common sense would dictate. The assessments that follow this may not be so thorough.

E: So Telemachus are you saying that any further assessment is in some way inferior?

T: No. Certainly not. We must identify the patient's variance from the usual path that patients take. It is different, in the sense that to repeat the first assessment might duplicate much effort.

E: Let me go back to comparing assessment and evaluation. What is evaluation? Or let me rephrase that question. What do you do when you evaluate someone's care?

T: Well you must look at the problems. Are they still relevant? Are the priorities correct?

E: Why do that?

T: In-between initial assessment and evaluation a care plan is devised, the problems having been identified. Then the care plan is implemented. We need to ask if the interventions are still appropriate? So we must look at outcomes. To find out what results have our nursing actions produced?

E: Yes, Telemachus. At least we can see the pieces of the broken pot, now the fog has cleared a little. So if I have it right, you have just explained the social context of assessments. What other contexts are there? Tell me what names would you give to describe these assessments?

T: As practice currently dictates initial and subsequent.

E: Is this initial assessment much studied by other caring practitioners?

T: Only rarely. They tend to be tied and forgotten. Perhaps on a Sunday afternoon the new electronic scrolls are consulted and reviewed, but the information contained therein seems wasted. Inaccessible to many. You either cannot read it, or the documents are in the wrong place at the wrong time.

E: So a great deal of effort may be spent gathering facts, and once set to the plan they are redundant. A waste of effort to be sure. You say the nurse focuses on the individual. What grounds have you for this?

T: Individualised nursing care is the bedrock of our practice. The nursing process is patient centered?

E: Mm. Take me back to the assessments. How do you know what to look for?

T: Models in the mind's eye, help us to model the real world.

E: So the external world is incomplete, as you have yet to recover the knowledge you were born with.

T: Yes, that is so. But I can use these models with supervision. There are many based on Epictetus, Hippocrates, and others based on nurse teachers such as Priam.

E: On the battlefield at Marathon what assessments were used?

T: We were forced to act as Gods. Deciding quickly who might be saved, and who already had a foot in Hades. E: So Telemachus tell me, do I have this right? There is a stage prior to assessment cogitation let's say, when we decide what the mental approach will be. What will be significant and what will not?

T: Yes. Just as you suggest. As usual you are ahead of me. And I do not know where you are heading.

E: Well let's see. On the field of war all men are equal. Mortality stands by them all, either as a shadow of panic, or a spear of courage to hurl at the enemy. What I want to know is - how do we get from the army subject to triage, to the cleric or philosopher in hospital with an individualised nursing care plan?

T: The patient's needs are identified, as noted earlier.

E: But that does not fully answer the question. How are the needs identified?

T: From statements the patient makes, observations and the physician's diagnosis.

E: So the nurses work according to the dictum of the medics? T: The physician's diagnosis is important in terms of the nursing care to follow, yes, but it is not definitive. The nurse also forms a series of diagnoses. E: How?

T: The problems are categorized, and that categorization is completed with the addition of the nurse's personality, like a master navigator who 'knows' his vessel and the waters, so the nurse 'knows' her patient and the course to be run.

E: So sick nurses can steer the troubled seas themselves? An interesting assumption. What categories are used?

T: The first is physical. Since to delay care of physical problems may threaten the patient's life.

E:But surely they are already categorized?

T: Sorry Epictetus, you have lost me.

E: The location of the hospital determines the problems the nurse will identify.

T: Yes, I see where you are leading. After some thought the same principle applies even on the battlefield. There we are not looking for appendicitis or tonsillitis.

E: But what of the mentally ill? Are they not at risk of their lives?

T: Yes, but they are mercifully a rarer occurrence than physical problems. Although exact figures are hard to come by...

E: So proceed with the categories.

T: The next are mental and social. I suppose these three are the main categories.

E: So is the nursing process applied to the individual?

T: Yes, it is.

E: But the nursing process has distinct stages, which remain the same which ever individual they are applied to?

T: It is the problems you seek then. They are the key to the individualised care plan.

E: And on the battlefield one model is applied to all.

T: Yes, I think so.

E: Can you summarize this model?

T: As I mentioned, the first question is who have the Fates offered a chance of life to, and who has already paid the ferryman. Next we ask who is sensible, who movable, and so on.

E: What happens in the general hospital?

T: Why, we find general problems. A host of problems from the man I described previously to children, slaves and women.

E: So the models used in the mind differ given the range of problems?

T: No. One model is adopted across the ward.

E: What about the patients' suitability to a particular model of nursing? Put trivially this assumes that patients respond to surgical procedures in exactly the same way. Do they - or might patient A's problems be better framed in Hippocrates' model, while patient B is nursed using the Activities of Living?

T: Yes, Epictetus, I see now what you are driving at. Essentially we apply the nursing process to the individual. The model of nursing on the other hand to a ward population. I must ask if there are several models to be applied to different patients on the same ward. Physical problems may be essentially the same, but the patient's psychological response will vary greatly. We may discern clear preordained pathways for physically ill citizens, but those with mental health difficulties present problems of granularity.

E: And does the presence of uncertainty suggest anything to you?

T: It suggests that we do not fully understand this concept of information. What is it? How do we determine its value in health? Our lives are cloaked in uncertainty. No actually it seems that life is shrouded in mystery, when the Gods remove the shroud to give us life, we find that life and health are themselves masked in uncertainty. Even when the Gods drape that shroud at the end of our days, the uncertainty remains.

E: Unless sired by Zeus or Odysseus a soldier does not leap from his mother's womb. He must be nurtured, educated, and even question those values he is trained to defend. For you and your nursing colleagues these questions and many others must be answered before you can proceed with this codification and your wider studies in informatics. Take heart. Before I take my leave of you, as my primary pressure sore area confirms my age, tell me what have you learned?

T: We have discussed the subjects of nursing - the patients, and the way nursing is conducted. Why things are done as they are. How is knowledge structured. Some important questions have arisen. It has helped to identify the areas that remain problematic.

E: Good. That's right. You must understand how these key terms - 'data', 'information', 'knowledge', 'value' and 'context' are used, the wider nature of health and nursing. Not forgetting this recording problem - just when is a record complete?

T: Surely only when a person dies can a record be said to be complete. If the managers want their contract data so be it. But we must simultaneously capture quality information, if they are to measure the art of health care. This they must do if policies are really meant to secure quality health care for our citizens. I certainly can't afford to pay Charon, and besides the dead don't respond to audit proclamations.

E: You are making good progress Telemachus. I must also say it seems that use of these machines will teach us much about ourselves. All you have to do now is prepare your arguments and convince your superiors. What will be your main argument?

T: That they must know exactly why they are creating data programs, coding nursing terms, nurses must learn to constantly question claims for clinical benefits. We have to realize that information is new as 'the' economic resource. Benefits and solutions to our problems do not flow from the very process of formalizing nursing itself.

© Peter Jones 1995

Citing this page:

Jones, P. (1995) Hodges' Health Career - Care Domains - Model, Change:

<>, Accessed

Suggested reading:

• Epictetus The Enchiridion
• Hospers John An Introduction to Philosophical Analysis, RKP, 1987
• Magee Brian Men of Ideas, Oxford, OUP, 1982 (Contemporary philosophy)
• Magee Brian The Great Philosophers, BBC.
• Plato The Thaetetus
• Plato The Last Days of Socrates