WHERE HAVE ALL THE NURSES GONE?
© Peter Jones 1991
Email: h2cmuk-at-yahoo.co.uk
A short story subtitled:
"... LISTEN NURSE, I’M SEVENTY NINE, YOU’RE EIGHTEEN -
YOU CAN’T SEE MY PROBLEMS"
ON THE WAY TO NOWHERE
[Sometime - first decade of the new millennium, on a university campus at 0830 hours.]
‘Back in college so soon and what's on the agenda for today?‘ thought Sue gloomily. She pulled her coat tighter and ran as the heavens opened. At that moment fellow student, Greg Alsing, joined her flight for shelter. Maybe he would know? Greg declared that they had to report to the ‘nursing informatics unit’.
Eventually they sat down. Sue eager for her coffee to do its work, remembered a note received yesterday. 'Why do we need the maths and computing department?' she asked. 'We already spend too much time away from patients.'
Gingerly placing his over-filled coffee on the table, Greg confirmed the details. 'Well, it isn’t just the computer department that awaits us, but the virtual health assessment and evaluation unit. It's part of virtual environments.'
'What has virtuality got to do with nursing?'
'Guess, I’m wondering too, but it should be fun,' responded Greg, 'but, we’ll find out together, because according to the list here,' shaking a piece of paper, 'we’re split up into pairs, and guess who Sue West is with?'
'OK, I’ll survive that fright,' with more than a hint of sarcasm, 'but what will we actually do there, surely not games?'
'Well as far as I know Sue it won’t be a bore if the technology’s up to scratch,' said Greg.
'But this is technology just for the sake of technology? I mean, the technology doesn’t mature, there’s never enough time,' argued Sue. 'Most of the time it dies in its infancy, replaced by something totally different, that initially costs two or three times as much. Where does it end Greg, tell me that?'
Their learning experience seemed far removed from the bedside already, without the computer hacks and academics sticking their oar in again. Feeling annoyed, confused, and frustrated, Sue’s mixed emotions provoked three questions in rapid succession: 'What on earth are we going to do over there?'
'Well I suppose ...'
'It’s all a waste of time and money.'
Much to Greg’s head-in-hands annoyance another question quickly followed. 'We need to communicate with people; their families; and ‘the’ community. Yes, now that was a really good placement you know.'
Rising as if in submission Greg shook his head, and pushed his chair back. Sue cringed as Greg's chair screeched in protest. She signalled an apology to a man nearby, disturbed by the noise, tucking into his breakfast. 'Look, we’d better go,' prompted Greg, nodding at the clock. 'It’s nearly five-to. It might take some time to find, never mind setup.'
They soon found themselves heading towards the basement. Although they hurried they read many similar signs - ‘virtual chemistry lab’; ‘virtual arts’; 'virtual exploration and control'; ‘virtual ballistic imaging’; ‘virtual economics’; ‘virtual encounters’; ‘virtual organizations and management’; ‘virtual psychotherapeutics’ - and many others. Due to lack of space some signs directed lost souls to temporary porto-units, they all had Web addresses listed. It seemed that the grand unification of all disciplines was happening down here.
‘Crikey, this is really happening,’ Sue thought, her curiosity stirring. What was going on behind these closed doors? Greg broke the silence. 'Hey, maybe I’ll finally get to lay-out my first dearly departed?' Sue stopped.
Greg had noted once before how, as if for effect, Sue would stop dead in her tracks to make a point. He hoped when she stopped in future that technology would not just roll over her. 'That’s not funny Greg. Most of us already have,' she said sharply. Greg scratched his head awkwardly, nodded an apology and tugged Sue’s arm, 'come on!'
Finally reaching their goal, they knocked and entered. A man approached them in instant welcome. His friendly face wore a knowing smile. It was the guy having breakfast in the common room.
'Hey, how did you get here so fast?' Greg asked immediately.
'Oh, there’s another entrance. That was, er, quite a conversation you had earlier.' At this Sue blushed, while Greg could not restrain a nervous cough. 'I’m sorry I had no choice but to eavesdrop.' Jeff could see their difficulty. 'It’s OK, yes really! I thought the points were well argued, and most relevant.' He smiled and they relaxed a little. 'West and Alsing isn’t it?'
The students responded in the affirmative, and with introductions exchanged they were ushered fully into the unit. Jeff seemed full of enthusiasm as he strode across the floor, bedecked with cables and ducts. 'Health and safety mustn't travel this far,' thought Sue.
'Mr
Jeff Bradley' the ID holobadge displayed, ‘Virtual Environments &
Social Engineering’. ‘Jeff’ it was to be.
'Welcome to ‘ENVY’, at least that's what the lead nurse tutors call it, that’s N.V.E. as in ‘nursing virtual environment’.'
Jeff checked the programme. 'Let's see. You’re here for two weeks aren’t you? You’ve had your lectures on integrated health, multidisciplinary and nursing theory? Ah, yes, and a session on "An overarching theory of health communication." Just as if,' he quipped.
'Nursing informatics with case study integration, a full six weeks! Good it’s all here,' said Jeff, hurriedly removing his jacket and tie. 'You’ll both be ready for a rest, but this week and next are no picnic. Virtual experience here, covering information science - ‘E’ and ‘I’ space, some anatomy, physiology, and the fundamentals of diagnostic medicine. I hope you both listened last college block. It makes life difficult otherwise.'
'Please read and i-sig the form that will arrive soon, mail it back to admin, then answer the questions, so we can record the sessions for you. I’m just nipping out, I’ll not be long. Don’t spill anything!'
The task completed, they moved to the main VR suite. Greg picked up a grey headset, a tunic and gloves. Both data-tunic and gloves were covered in sensors, the headset too probably. Sensors translated the wearer’s movements into the equivalent movement of a computer generated figure inside a supercomputer, such as Greg was examining on the desk.
RENDERED HELPLESS
'Hey Sue, the latest systems laser scan you in. What's this? Oh great, they've got facial mapping too. The cameras can also convert from 2D to 3D in real time, this looks promising!' 'That’s wonderful news!' quipped Sue sarcastically.
'Oh come on, Sue. Don’t forget, be non-judgmental in all things, keep an open mind. I’m quite excited about this,' declared Greg.
'So, I’ve noticed. But you tell me what the difference is between these machines, a spinning jenny, and the supermarket till my aunt used to operate? Since Netsgo shopping services took over all those supermarkets have gone rural again - deserted dandelion parks. And all those telebanking workers losing their jobs. There’s a big difference between skill enhancement and productivity enhancement!'
'I suppose there could be,' admitted Greg half-distractedly, his attention focussed on the headset. Built in were two rectangular screens, headphones, and a microphone. The small but very high resolution screens inside, completely filled the wearer’s field of view. The computer display to each eye differed very slightly, providing the wearer with 3D visual information. A 3D binaural audio link reproduced sound as heard by our ears, so the position of another person’s voice or other sound in the virtual world is reproduced directionally, an extra perceptual cue. Greg put the headset on to meet a black, silent, informationless void.
'So Greg - you'll be first.'
'On the contrary; all three of us are having a go,' interrupted Jeff returning. 'Come over here,' he beckoned. 'We all have some teaching to do.'
Greg took off the headset to join Jeff and Sue in the interactive educational area. The plants, colour scheme and furniture were relaxing, in contrast to the gizmo garage. The ergonomic lessons derived from the stress laden 'aching eighties and nineties' were trying to bear fruit, if the technology would stand still long enough.
Jeff called up a 3D rendering of the unit. An image suspended in mid air appeared beside the PC, on which Jeff’s video image also appeared. 'First, I want to spend explain the equipment and how you will use it,' said Jeff. 'We may know how to prevent RSI, but VR still creates its own unique problems. This isn’t a total immersion VR system,' said Jeff half-apologizing. 'We don’t need that degree of sophistication here. Some arts have total immersion, as ever costs play their part. This isn't Aardman Studios!'
The door opened and two people entered acknowledging Jeff and his companions. 'Ah good,' said Jeff. 'Here’s Kylie and Joe. They have other work to do, it seems archaic, but we need somebody real-side - for safety.'
'It sounds like we’re off to see the pink elephants,' said Sue.
'Oh this is far safer than drug induced trips,' claimed Jeff. 'Yes,' said Sue, 'but what about the need for control, if virtuality is so pleasurable can’t people become addicted? Look at the kids with rec-drugs; coffee; networked VR games; and gambling; their studies suffer. Then society suffers.'
'That’s right,' reinforced Greg. 'Drug, child and family mental health services still can't cope with the referral rush.'
Jeff thoughtfully accepted Sue’s point. 'It’s true there are dangers, like so many things the scope for abuse is always present. Many tools can become weapons for the abuse of self or others. Look, I don’t want to dodge these issues, but the systems set so let's get on.' The training continued: visual and kinaesthetic adaptation; speech recognition; command options and selection.
Finally. 'Oh yes; when the system is activated you will see a static pattern at first, I’ll talk you both through until you’re oriented. Your eyes may strain a little, despite adjustments for optical prescriptions and a focus distance of 30 cms. The headset is lighter than in the late 90’s, but ninety minutes here should be long enough first time. Once more I have to refer you to the disclaimer that you enter VR at your own risk.'
With that Jeff helped them into their data-tunics. The headsets were fitted last. Once the explorers were ready, Jeff spoke via his mike.
'Remember, you are safe on the couch, but in VR you’ll be suspended in space. Below and above us will be a grid of lines. We will be in a triangular formation to start with, and clearly visible to one another. Right. Are you ready?'
'Ready Jeff,' they responded, not knowing quite what they were ready for.
Jeff gave the command to the system - 'Commence ENVY 2' - that in turn gave birth to a virtual world.
THE JOURNEY: SO SECURE IN THE KNOWLEDGE
The black informationless void before their eyes was 'gently' replaced by an awe inspiring panorama. Sue and Greg gasped in harmony. She smiled to hear Greg catch his breath.
They were indeed suspended between two vast planes, paved with rectangles, with irregularities in the distance. Distance? Scales here had a definite fractal quality.
They instinctively looked around them, as if searching for a familiar landmark. But, except for three human figures and an arrow to suggest 'up' there were none. Her companions were clearly visible in the near distance. Flesh now moulded into trillions of invisible polygons. People ray traced by an algorithmic hand, freed at last of gravity. Their legs missing, like some future space living race, or did they have phantoms limbs here? Visually, Greg and Jeff were stripped of their humanity. There were few earth tones to see, the colours garish, cybertones for cyberspace. Ironic the meaning of rendering real-side and in this world.
Then Sue realized that she too was a member of this cyberworld. She shivered, and wondered if the computer betrayed her temporary unease to Jeff and Greg. It did not, but what did the others see?
'Are you both OK?' asked Jeff. 'Erm.. yes I’m fine,' said Greg. 'Me too Jeff. Now I know how Scott Tracy feels, but without the strings,' joked Sue, her voice a trifle nervous.
'Cripes,' said Greg, 'I bet the systems even captured my acne.' 'Don't fret Greg, my face never looks right in here,' said Jeff.
'OK, as a practise, move towards me. Point towards where you want to go. You don’t have to extend your full arm remember. It’s awkward at first, but you’ll soon get the hang of it.' 'Hey, is that a joke?' asked Greg.
Sue pointed in the desired direction. In response she moved towards the figure of Jeff. Off to her left she could see Greg doing the same. She did not know how, but she could tell who was who, even when ‘flying’.
'Hey, this is really nifty!' Sue enthused. 'But I still want to know what’s this got to do with nursing.'
|
'Give me an hour and I’ll try
to show you,' said Jeff, who now appeared about six feet away.
|
 |
'Yes we can,' said Jeff. 'The key is telepresence, which the entertainment market are, erm... well, rather interested in. Basically, it’s the transfer of pressure information.' Jeff uttered a few instructions. Instantly all three were linked. At first Sue and Greg felt an odd presence near their hands, then a reassuring grip as ‘contact’ was made. 'Hey,' said Greg, 'even if I couldn’t see you both, I’m sure I could tell your hand’s apart.' 'Why,' said Sue sardonically. 'Who else do you expect to meet - Marilyn Monroe?'
'It'd be pretty sinister, if it was someone from afar who was touching you, when you thought it was someone close by,' said Sue shivering. 'Yes,' agreed Jeff, 'VR brings a whole new meaning to verbal and non-verbal communication. Suddenly, over there, isn’t over there any more.'
Sue 'released' their hands. 'It’s really odd, not having all the visual cues that we normally use when communicating in the real world,' observed Greg. 'Yes,' said Sue, in total agreement.
'Emotionally it’s a desert,' said Sue. 'What is it they say - 'in outer space no one can hear you scream.' What I’d like to know is - 'in VR who dries your tears?''
'Oh that’s easy you just take your goggles off,' piped Greg. 'Actually, I don’t think that quite answers Sue’s question,' Jeff suggested.
'Well, you both seem to have the idea,' Jeff continued. 'Let’s venture further. Point towards the yellow-white light over there. That’s it, we’re off.' As they moved it became apparent that what lay before them was not just a light, but a vast metropolis of moving lights. Pulses of lights raced to and fro along lines connecting shapes of various size and colour.
'What on earth is it?' questioned Sue, 'it’s like a city at night, frantic with traffic whizzing about.'
'We’re moving towards the (HINT) health information network. The university is connected for training and research purposes.'
'And for confidentiality certain details are missing.'
'That’s right, Sue. The computer substitutes the real name and critical information like sex, and date of birth, but the clinical data is genuine,' said Jeff. 'The computer is programmed to handle data interchange according to the context.'
'Such as?' Sue asked. 'Surely if some things are changed then the context will alter dramatically.'
'Yes there could be problems, medical conditions and nursing procedures were gender is very relevant - like obstetrics for example. Cases could quickly become nonsensical if limits were not imposed, but they are.'
'What about the special clinics, BSE, Aids, STDs, that sort of thing?' asked Greg. 'On certain units restrictions apply to all staff except those with special access.'
'Could I see the records of a neighbour?' asked Sue.
'That’s a good question' Jeff replied. 'No, in theory you couldn’t do that because the computer knows your address and if a similar address, or name arises, it will change just to be safe. In fact a background task runs to constantly check on many details. If someone has a very rare disease then access is strictly controlled, because of course substitution would not work then. We have to comply with the new Information Protection Act. The heuristics are very complex and managed with the support of an expert system; it prevents us and other info-users from building too complete a personal data profile (PDP) on a specific individual person. Those last three? mm, four words are important and are needed. We're not talking about individuals with a diagnosis; persons with certain criminal records or overdrafts. We've to thank The World Court, EU and civil rights people for the IPA. Someone had to reel in the more unscrupulous companies and scientists, trying to patent the genetic resources of indigenous peoples and fauna. Something really had to be done.'
'Yes, I recall the arguments on that recently,' commented Greg. 'But with a global ID number, aren't we more at risk?' challenged Sue.
'Oh, well that is something we are getting to grips with,' claimed Jeff.
'Biometrics?' Sue split the word without hesitation. Bio - ‘body’ and metric - ‘measure’. Greg was also on the bounce, 'Who was it who said that 'Man is the measure of all things?''
'Ah, yes but now 'Technology maketh man, woman, and nurse!'' added Sue combatively. 'OK!', said Jeff, 'let’s get on with this.'
'As I remember on my last security update,' said Greg, 'an ID badge or card is something you have. A PIN or other ID Number is something you know, but - and crucially for us, clinicians, politicians and ardent capitalists - biometrics is something you are.'
'Like fingerprints, DNA that sort of thing.'
'That’s right Sue. You can also add to the list - retinal prints, voice, and even body odour. The headsets we’re wearing are in fact two way. The system knows you are here via retinal print. Your time and location’s also logged automatically. An excellent training log, a memory prosthesis. It is obviously far more difficult to steal a person’s retinal pattern or fingerprint.' 'Hold on,' said Greg, 'when did you get that?' 'When you started training. Your national id card is the basis for your student card.'
'You mentioned - 'in theory' - earlier Jeff,' queried Greg. 'That seems to imply problems?' added Sue.
'Yes, there are still problems - any ideas?' he responded. 'It must cost a lot of money to implement all these measures, and ensure that staff are au fait with them.' said Sue.
'Yes, security or peace of mind does not come cheap, and no system is 100%. But biometrics is much more secure than PINs or badges.'
'But you still need a copy of say Greg’s retinal image on the computer in order to do a comparison. That must be a weakness?'
'Yep... well spotted,' praised Jeff .
'Encryption can be used to secure the copy of a biometric characteristic on computer, to help reduce the risk of unauthorized access. A further point though - is that we depend on a ‘complete’ health record. As ever the computer can only process data that’s input directly or accessed from another system. If information is left out, then as ever things fall down.'
Greg interrupted, 'but I thought some data values are made mandatory?'
'Yes, but there are still anomalies, over the years not everyone agrees on which data items should be mandatory. Data sets change in content and format, becoming a legacy themselves. You could say the models wear out. For example, biotech, globalization, arrival of infoports, and the integration of health, social service and other Governmental information systems showed up the inadequacies in the Data Protection Act.'
'So,' concluded Jeff, 'the real question is: When is a health record complete?'
'When a person dies, I suppose.' answered Sue, in a flat tone.
'Yes,' said Greg, struck by Sue’s perceptiveness, 'that sounds right to me. At least... unless
they have a donor card.'
NEVER NEVER LAND
As they travelled Jeff returned them to the matter literally at hand. 'We’re nearly there now. Of the shapes you see, the blue hexagonal block is the provider.'
'What is the linked red circular 'block' above?' asked Greg.
Jeff was in his element now. 'That’s the family health services authority. Let's move closer. Where do you think the data comes from?'
Sue stated that the blue beams raining down from above must be from GP practices. The numbers seemed right, and the beams varied in breadth according to the size of the practice. It looked like an enormous pin cushion, or a ripe dandelion head waiting for a virtual breeze.
'Yeah, Sue you get the idea, the red block is the community system, with links all over,' said Jeff. 'I’ll say,' agreed Sue.
'Hey, now we are closer,' Greg noted, 'Some of the data streams are not deep blue, why is that?'
'That’s an indicator for the size of practices,' answered Jeff. 'There’s something else here,' pondered Sue, 'I can’t put my finger on it...' 'And what might that be Sue?'
'It’s the GP practices... Hey, is that Wolfson’s medical centre, the large one, and West Street Surgery?'
'Yes, it is.'
'Well I’ll be ..... they’re all positioned according to their actual geographic location.'
'I think it's time to get the help,' said Jeff, and instantly three blobs of seemingly energetic light appeared. Sue flinched, but the reflex was useless here. Each orb was the same colour as the person they were now 'attached' to.
'It’s all right these are your agents. If you need anything, more details, or less, a reference perhaps, the agent will fetch it for you. Just address them as 'Tink' or 'Agent', they are programmed to respond to your voice alone. Regular users can customise them.'
'‘Tink?’' asked Greg.
Sue provided the answer, 'Oh, come on Greg. Flying like this we’re bound to see Peter and Wendy soon.'
'Ah, yes of course,' he laughed.
'Now we must head towards the blue block. We need to draw some data and create a patient profile.' 'Better data, than blood. Where do you get the data from?' asked Sue.
'The black obelisk over there is the server, the main repository, the pulses flashing are information writes and reads, system updates, when a nurse alters some data about a patient on the ward the change is reflected in the infobase,' Jeff answered. 'In fact you are witnessing a representation of the actual system. The flashes occur when actual operations are completed. At the moment there are so many per second that to you and I they fuse into a continuous hue.'
'Why the different shades?' queried Greg.
'Well, certain files are locked for a read or write operation; so other users cannot access at the same time and cause data integrity problems.'
'Why not put signs on the buildings?' Greg prompted. 'You do it, you know how to now,' reassured Jeff.'
Greg ably complied. Their earlier training paid dividends.
They were close enough to see the ‘buildings’ alter slightly. Labels appeared which changed position so as to face them as they changed their approach and perspective. Sue could not be unimpressed by it all. Greg was equally amazed, at the scale and complexity of this virtual world. Especially now the data input and output streams were also labelled.
'We could have the buildings modelled on
the real things,' offered Jeff, 'but it slows the system down due to
the need for detail. We still need to balance content and aesthetics.'
'The labels come into their own in anatomy, physiology, and all the other sciences. Agents can label according to academic level and personal choice. That way everyone can follow at their own pace.' said Jeff. 'A tutor's job in VR training, any subject, demands great skills. As ever the military were here first, I guess Caesar would have loved this. Actually, below us now, some med students are training. Nearly twenty years ago, a body left to science was sliced and digitized. Anyone can access that data and the latest efforts on the Web. You can observe a surgical procedure, or a post-mortem if you can handle it. It’s very realistic! They're honing their virtual surgery skills now with the help of robotic assistants, terrific progress is being made. The neuro-knowledge base now grows so fast.'
Jeff explained their new environment. 'That crimson glow are junctions for the GDN and WDN. The green beam carries data to and from social security.' Sue had heard of GDN - ‘government data network’ - whereby social, health, law, taxation and customs are connected together - but WDN was something new. 'What’s WDN?'
'I was hoping you'd ask. WDN is the World Data Network - the GDN is just one of a hundred or so, which all Governments should have in place. If we are to allocate world resources fairly then a WDN makes sense. The aims of ‘Health For All 2000’ were very worthy, but if we are to better that, and we certainly need to, then all people should have access to education for life. And the WHO needs information, fast and accurate. Ten years is too long a time frame. Now with talk of a new organization World Union or Alliance replacing the United Nations, the globalization of health is finally mirroring that found in economics. Satellite surveillance finally means countries are now more able to spend a higher proportion of GDP on education and health promotion, rather than weapons. Who knows in ten years we may start to build the space elevator, save blasting holes in the ozone layer. We've already applied for approval for a new space nursing curriculum, with ESA and the UK space centre. Scuse me I get carried away.'
'That's OK, so are we Jeff,' reassured Greg.
The computer generated world they travelled in was a marvel to behold, parallel lines ran off like so many railway lines; their destination - infinity and beyond. Pulses, quanta of light zipped hither and thither, tripping, dancing to the beat of an inaudible digital drum. A drum, eerie in its silence. In one section the frenetic data dance was halted to a apprehensible pace. Data packets scurried between information ports. Digital guards unzipped data packets, once virus scanned, audited, checked and validated they were repackaged, while other guards leapt on other suspects.
The areas now below were whole subject areas they could literally dive into. A virtual tour of classical Athens, Pompeii and Herculaneum, or the island of Thera before and after a certain cataclysmic volcanic eruption. Stonehenge - one of the first VR projects. The virtual hospital with its multiple access points. An icon showing the sun, Earth, and moon beckoned the astronomer; the chemists could pick out the test-tubes and atom; the moons Europa and Titan tantalized the exobiologists; an artificial neuron the endophysicist.
The icons were static, waking into 3D
action as any user neared, immediately more appealing even to the most
disinclined student. The moon did what the moon does best, never
two-faced, following its solitary orbital path. But no lovers gazed up
and dreamed from that blue virtual Earth.
At least so Sue thought. Could it all be VR?
'What’s the huge cabinet-like affair?' asked Greg. 'Ah yes, that’s a shared facility for physics and chemistry. They’ve taken the periodic table of the elements and turned it into a marvellous teaching tool. It started as a college project I think. It's become a global effort now, complete but continuously refined.'
'How’s that,' queried Sue.
'Well 3D graphics model the elements. As they used to say in computing - there’s no substitute for hands on experience. In the virtual system students can experience first hand the atomic and nuclear forces acting on atoms and molecules. For example, elements essential to life can be displayed, so students can explore the physiology and chemistry mediated by a particular element. Sodium, zinc, potassium, iron - there all there.'
'Have you tried it?' asked Sue.
'Yes, it’s brilliant, but without customization and practice it can be tiring. The torque and forces of the molecules act on your arm and shoulder. Imagine describing that as RSI over the net to your doctor, thank goodness for decent videocoms. You really appreciate the forces inherent in the micro world. Such as the structure and forces at work in a cell. D'you wanna be a water mite? Ever tried breaking the surface tension on a pond?'
Sue wondered what Florence Nightingale
,
Aristotle and Hippocrates would have thought of this. What form will
the seven wonders of the virtual world take?
Approaching another area, Sue realized they were not alone. 'Are they people down there?'
'That'll be trials. That section’s used by physio for physical therapy.' Suddenly, an opaque screen, like some virtual frosted glass, appeared to obscure their view. Sue sighed in disappointment. 'It's odd, but people still value their privacy, even in here,' Jeff consoled.
'What’s physical therapy - exercise?' suggested Greg. 'Yes, basically. Patients get bored with having to raise their injured leg x number of times. Here in virtuality they can do the exercise but the movement is linked to another activity, like creating an image, or music. They can select a painting tool, the angle of their leg may alter texture, the speed coverage of paint.' Both students laughed. 'Well something like that, anyway,' said Jeff defensively. 'If they try to make prohibited movements, the physio expert system warns the patient. By altering the motivating factor patients enjoy the exercise.'
'That makes really good sense, a definitive application if ever there was one. Like the VR sets at the dentists, and estate agents.' declared Sue.
QUESTIONS WE ANSWER FOR OURSELVES
They approached the repository. 'Point towards the wall,' urged Jeff. 'It’s OK you can pass through. We'll add full audio now too.'
As they approached the wall before them dissolved. They entered a space that appeared so big echoes would get lost. Closer observation revealed several ghostly outlines, waiting for their moment like unavailable menu options.
'This,' pronounced Jeff smugly, 'is the PMF...' Sue responded instantly her voice suddenly uncertain, 'What on earth, is this place, it's weird?'
 |
'We call that the Tardis effect,
you've just passed a scaling boundary. Bit naughty really. VR is
nauseous enough as it is,' Jeff explained.
|
'Nurses also want a professional utopia, here at least they can have it. The potential is unlimited resources to deliver the exact nursing care a patient’s problem or nursing situation demands, surely ideal for training? At last the MDT will be able to learn together here; audit; care pathways; protocols ... ' announced Jeff proudly.
'And is this supposed make us feel better - to compensate - for what it’s like realside?' argued Sue. 'I still can't believe the taxes we're paying. The bit tax really bites, as the protesters say.' 'No, of course not,' Jeff said, 'But students are always working at odds with the educationalist’s ideals and philosophy and that on the ward or other clinical area.'
'So,' started Sue, 'the holy grail and the virtual bed-pan do exist? That should make for an interesting patient-nurse interaction? Especially in the community!'
'Give Jeff a chance Sue,' Greg pleaded.
'It's OK we're far from finished yet.' Jeff paused, and changed the subject. 'TLAs abound as ever. This is what we call the problem modelling facility, PMF for short, it contains a P-space. That is a problem space. Every discipline has its P-space, built on an epistemological - knowledge - space,' Jeff explained. 'Such as?' asked Greg.
'Well.., disciplines from aerography through to zoology. It may mean that physicists don’t waste billions of Euros, they can skip a generation of gluon smasher using a virtual lab. The P-space is structured in various ways to accommodate the knowledge base. Of relevance to your people are the P-spaces of biology and anatomy, psychology, sociology, epidemiology, nursing of course, and others besides. A major global project is a classification, a Dewey index of knowledge for the 21st century. This is feasible in VR. The P-space is configured according to the context, it might match the problem profile of the patient, or the various parameters of a hypothetical nursing care problem, even an ethical dilemma. If the problem is ethical in nature we need a warning though, such problems can demand an awful lot of processing time, especially if time is a factor. Fuzzy and temporal logic solutions are improving, but there’s still a way to go.'
'I thought health was supposed to be multidisciplinary?' queried Greg.
'If each discipline, like - social work, OT, physio - has its own p-space then how does that help?'
'That's utopia for you. One benefit is that each discipline can explore the P-space of the other. That must help? There are new hybrid models, health models that take into account the multidisciplinary, client centered perspectives we have strived for so long. And models that combine the concepts of holism and information.'
'So we can get to see that social workers don’t just sort out benefits, and they can learn that nurses don’t just ferry bed-pans and give injections,' suggested Sue. 'Well, hopefully we’re not as backward as that these days, but that’s the idea...' confirmed Jeff. 'Each discipline can see where their respective curricula overlap, and predict future trends. It’s all still quite fuzzy, but we’re getting there.'
'It sounds to me like the next generation of skill and grade mixing, a sort of Euro-integration exercise,' Sue complained. 'What’s the point in having social workers and community nurses if they possess similar skills, why not merge the roles? Isn’t that how such a tool will be used?'
'You mean abused,' corrected Greg. 'It's not that simple, and you both know it. Look at GPs, there role has changed in a major way these past ten years. Now the job is more rewarding, less stressful, recruitments on the up again. Jobs change, roles change, life and society changes. You don't remember the 80's - do you? People have to cope with change, that's what life is about now,' Jeff said emphatically.
'Speaking of - ward - life then, if we currently sit with patients and discuss care plans and goals how does that fit in with this set up?'
Jeff moved closer, social habits die hard. 'Good question, Greg, soon selected patients will also enter P-space, to agree care plans and monitor progress, some panes may be withheld according to the context of the session. We hope to have students here regularly as well, but under supervision.'
'Ageism accepted, surely you don’t really believe that elderly people are going to don headgear - however comfortable - and agree their CPs [care plans] in here?'
'Why not Sue, many of them already do - enter VR that is. VR gives freedom to people of all ages. It can give them the ability to ‘do’ things they would not otherwise be able to do. Disabled persons - a case in point. Independent living has really taken off with information technology, helping in cognitive rehabilitation too.'
INTO THE COMMUNITY
'We need a patient Sue?' The ether was silent. 'Sue are you with us, over there?' A pause, then... 'Yes. I’m here. Sorry; all this seems completely OTT.'
'Do you want a break, Sue?'
'No, no it’s OK. This is just mind-boggling that’s all.' She considered the question put to her. 'Where do I enjoy working?' Once again a mike appeared at Sue’s top left. Jeff had explained this would happen at key stages, recording for future reference.
'I enjoyed our last placement - community. There was a lady - Ethel - who had a load of difficulties, she was seventy, had dementia although her personality was still quite intact. Her family weren’t very supportive, except that is for one daughter, Janine, but she lived thirty miles away. Oh and two dogs, she lived for those dogs. They made sure she got home, and knew the time of day. Her sons lived abroad, another daughter, Sadie was trouble. Ethel was afraid of her, she racked up Netsgo shopping debts in Ethel’s name.'
'The house was damp. She suffered chest infections, weight loss; and hypertension. Agitation, and depression complicated matters. All-in-all Ethel was a mess, but a lovely lady. Despite this she wasn’t deemed at severe risk. Sadie said she was fed up of care services not looking after her mother. She never called daily as she claimed, but still got carers allowance. A neighbour contacted social services anonymously about Sadie's shouting and Ethel’s reversed sleep pattern and lack of support. She was admitted a few times so I met her there too. I bet she's in an nursing home now. Top floor with not even a goldfish to talk to. Or maybe she has had enough and is dead now!'
Sue's distress was obvious. 'Are you sure you want to carry on? You can select someone else, a simulated patient if you want to? Perhaps on the other hand, it would be useful to review your experience?'
Sue sighed audibly, 'I suppose it’s easier relating to someone I have known, even though this upset me at the time. We can intellectualize all we want to, but it doesn’t change the facts,' Sue said pragmatically.
'The attitude of Ethel’s family really creased me up. Apart from nursing staff and Janine flying to-and-fro she was alone. I never got to say good-bye,' confessed Sue. 'I'm just soft, too involved. She probably wouldn’t remember me now.'
'Yes,
that’s true I suppose,' Greg agreed, 'but it's the caring for
that and each moment that counts.' 'Yeah. Maybe it’s a bit more
complicated,' mused Sue. 'How’s that... if you want to tell us,'
said Jeff, concerned as to whether this was the place to counsel
someone.
'A relative died recently,' continued Sue. 'I’ve never lost anyone so close before. What with that loss, and experience on the ward.' Jeff and Greg remained silent, to good effect.
'Actually, I remember TV showing VR for bereavement counselling. Maybe we should all make a "record of love." In case we become ill, or suffer a fatal accident. In China because of the shortage of land, they're trying to encourage cremation, but thousands now use the Net daily visiting little shrines along the info-highway. Posting messages to their loved ones. They say it makes the loss more bearable. I wonder, virtual space, inner space, outer space, spiritual space. Are they the same? I suppose there are some questions we can only answer for ourselves,' said Sue thoughtfully. With that Sue regained her composure. 'Look stop fussing. I want off this virtual couch I seem to be lying on, but I'll check out that site later.'
'If you're sure then Sue? Let’s see how Ethel’s care shaped up - ‘shape’ being the operative word,' noted Jeff. 'What so quickly?' said Sue in surprise.
'Well, the computer knows who you are, and knows who you have nursed since starting your nursing career. In fact the computer has a model of you both built in, your ages, interests and hobbies, experience in nursing and other employment. You were the primary nurse for Ethel, just at the start of your second year. Is that right?' 'Yes.' Sue agreed.
WE CAN SEE (P-SPACE) CLEARLY NOW
'Alright, let's see what we can conjure up.' Jeff composed himself and the system for the input. 'Construct one P-space: Place all data from DOB [date of birth] on life line, superimpose health career, all medical and nursing domains. Use 3 dimensions and add time, default access point. Summarize all hospital, GP, community, and voluntary episodes greater than 14 days duration. Standby family and genetic histories, assign objects to agents for subsequent access. Include face-to-face, proxy, conjoint, shared, and multidisciplinary contacts. Make available investigations. AV on all channels. Primary user focus SW. Secondary, GA. Confirm. ... End message JB.'
Right before them a massive cuboidal shape appeared. A through corridor took shape, its walls started to cry? No they seemed wet with stacked semi-translucent panes of data. All types of data: structured data - relational, spatial, multidimensional; unstructured red text, cyan, green, prescriptions, diagrams, and other images. Data streams - videos of gait analysis - but that wasn't Ethel? Magnetic resonance images, ballistic scans, drug molecules, all flowed onto the panes, stacked in organized chaos. At certain points the data was highlighted, hyperlinks were visible through the roof, where a hyberbolic view of all the assembled data was displayed.
Sue was open mouthed. An appropriate facial pose as she recognized fluid input data, diet sheets, drug regimes, and then nursing care plans, assessments and evaluations. Discharge summaries and ubiquitous patient satisfaction questionnaires; the paper copies scanned, tea stains and all, OCR forms trimmed, and qos (quality of service) smart cards 'naked' and read, divested of their protective covering, and e-tag to prevent loss. As Jeff had explained if she concentrated on a pane long enough the displayed data automatically enlarged, and was displayed at even higher resolution. Now that did disorientate!
Sue noted that she could move her virtual self or have the data slide by within the cube. She ‘floated’ as this seemed more natural. And before her - an assemblage of all the data relating to her patient now christened at this digital baptism. Then, an image of Ethel herself appeared, rather incongruous to Sue as she looked so well, younger even - from all angles!
A key led the way just forward of and
below her left shoulder. Data that was raw and primitive was red. Blue
represented censored data, needing special access codes. Cost
information no doubt, destined for the pyramids flattened top? Highly
transformed data, items that had been subject to calculation or other
processing was an easy-on-the-eye green. Volumetric data showed
yellow. A pale blue cyan colour designated the permanently archived ‘hardcopy’
record, duly signed and dated. Now at last records were records, who,
what, when, where, why: and people could read them never mind
machines. 
Sue (and Greg) were in awe. Despite the deluge and its extraordinary genesis ('something from nothing, hey isn't that how it all began? '), Sue and Greg knew what was what. The interface and VR environment had obviously been excellently researched and tested. It was an almost religious experience being within this obelisk - a temple to data, or was it information, or knowledge? She didn't know which? But where was patient care here? Lost amid the torrents of bits and bytes that whizzed around, over and under her.
Sue felt overwhelmed with the speed and sheer sense of data volume, not just that sensible now, but the volumes the system held in check. Terabytes, petabytes - the strain was mounting for Sue, and Greg too, when Jeff’s excited tones interrupted her reverie, revealing telepathic empathy. 'We can reduce the data, if needed. If this is too much like a religious experience, then it can be damaging - you remember the cases of polyinfoemotive psychosis?'
'The higher up the wall the more abstract and possibly less relevant the information, unless you re-query then things will alter, that includes Ethel’s demographic characteristics, family, social and medical history. Up top you'll find links to related research, via the e-map.'
Ahead tabs were suspended in space. One indicated a genogram - a family tree. Sue accessed it, with a cursory wave of her hand. A social network analysis option was available. As she progressed through the living years, Ethel’s family changed as families must. Tom, Ethel’s husband’s records became available. Should she have access?
Sue noted details of Tom’s physical examinations conducted at age forty eight, another at fifty two, and episodes of illness in-between, the first signs of cardiac trouble, at forty two. Pausing Sue witnessed a dynamic graphical [fractal] representation of Tom's heart as a symmetrized dot pattern, blinking on and off. Why? Then Sue noted some irregularity within the images, as the dot pattern alternately superimposed over an image of a normal heart. The computer matched the patient’s anatomical characteristics, automatically scaling the image projections. The display blinked, first the normal then the abnormal pattern, Sue could see the problem flash out its presence. Once, a deadly beacon now redundant - a historical remnant. Born of a living entity; now incarcerated - like the body from which it emanated - but here in a data cemetery.
Remembering their training Sue touched her ear. The sound of the ECG recording displayed before her boomed out. Instinctively, Sue wanted to turn. Was some monster about to grab her? Seemingly as large as a bus, a scarlet pulse of light traversed the PQRS line to the beat of the cardiac tune, only to fade as she 'passed' beyond its scope.
Sue placed her virtual hand in two data streams above. Tink responded - 'those are audit and educational streams.' Fields of data awaiting an information and knowledge harvest. Sue realized that the computer was 'grabbing' material that she might call upon. Topics included the cardiac cycle; mitral stenosis; pharmacokinetics and pharmacodynamics of antidepressants; and other subjects related to Ethel and her family.
Icons showed the readiness of browsers and tools for coding, information retrieval, and grouping: the Read codes version 8, ICD-12, the Unified Medical Language System and new integrated versions of these tools. Sue could see the system anticipating her needs, dynamic reasoning essential in most fields of VR. The relevant nodes and links were highlighted, from one level to another. The computer 'knew' how these subjects and their concepts were associated with each other. The semantic network provided a powerful teaching tool in its own right, especially in its multilayered e-map form.
‘Yes that’s I.T., ‘CPU’
really means computers process us, ’ thought Sue.
‘OK, computer sort this one out,' Sue challenged. 'Input SW: Tink find all transfer of care and similar events, display in sequence from last April to present.' Tink responded immediately.
‘Seven transfers of care for period specified, including respite care episodes.’
Sue surprised, investigated further. 'Where is Ethel now?'
‘Ethel is currently occupying a respite bed at St John’s,' ’ the computer responded.
'Display a list of care transfers,' asked Sue. The list appeared. Two previous respite periods in social service and private care, returning home after each. ‘Hey, hold on a minute,’ she pondered. 'Who is caring for Ethel when she is at home?' Sue demanded while trying to deny her personal hopes. ‘Her daughter Janine.’ The machine declared neutrally.
'Oh, brilliant,' rejoiced Sue, 'she’s home after all!' Delighted to see Sue so pleased her companions joined the celebration. 'Now that is really great! I didn't know - honest!' Jeff exclaimed. Greg forgot himself - tried to applaud: and found he could. 'Let’s see how Ethel’s shaping up. Greg, we need your help too.' 'You got it,' he duly replied.
Jeff issued a command. 'Integrate and analyze past ten months to current problem profiles, of Ethel and her daughter Janine.'
A smaller evaluation cube appeared. The cube was also displayed in plan form, to aid navigation. Through the problem panes and within the evaluation cube, a 3D semi-transparent shape formed. It was a complex shape akin to a icosahedron with twenty plus faces, but irregular in shape, both smooth and spiky. Three axes crossed through the centre of the cube and this evolving amorphous shape, to extend just beyond its boundary. A label for each axis was suspended in space: vertically - individual to group: horizontally - humanistic to mechanistic; the z-axis was certainty to uncertainty. Becoming more solid, the figure's surface colour changed tone gradually as it filled the space within the cube and between the three axes.
'We’ll map the sequence from the time line corridor to the health career shape Sue. Greg you read it through.' With permission granted, Greg found himself linked to Sue’s visual field. Now he could ‘see’ what Sue saw. Quite handy - swapping heads. The computer continued to alter the problems.
Greg selected options from the evaluation, merely by looking at them. His enthusiasm evident, Greg read avidly like a child might read an old comic. He accessed data panes, like so many action packed drawings, with surprisingly deft gestures and movements of his hands and eyes. 'When carers enter they as ever will have their own assessment, and create their own view of their relatives problems,' Jeff added, trying to cover all angles. 'They share our view unless the patient consents.'
Within the PMF two profiles were now linked and colour coded, Ethel’s and her daughter’s. Greg dealt with their psychological state. P-space showed Janine’s anxiety, powerlessness, and the critical points of decision. She gave up her job in order to care for her mother. BADS and other tests of Ethel’s psychological state showed her to be struggling cognitively and behaviourally. As time went on Ethel’s mental and physical state improved. P-space reflected this visually in colour and audibly. A pleasing tone could be heard, as problems and uncertainties changed positively.
'Show optimal boundaries,' Jeff requested. An outline appeared to show the probable optimal benefit Ethel could derive based on objective attributes. The P-space revealed financial, social and psychological impacts of Janine’s decision to care for her mother. The display varied in accuracy from actual values to estimated values and coloured ranges.
'It's time to save your records, we’ve to finish soon, any questions?' asked Jeff. Greg figured that there was something pretty powerful here, apart from playing virtual God with people’s lives. 'The volume of the shape, Jeff, how does it relate to the person’s problem profile.'
'Well,' Sue suggested, 'if the problem definitions are accurate then the volume could be a function of sorts. I mean you could provide someone with a score - a measure of health status perhaps, or whatever parameters are used on the axes.'
'Yes, that’s right Sue,' praised Jeff. 'But hold on a minute,' said Greg, 'how do we know the problems are well defined and the weights assigned to them are accurate.'
'Yes,' agreed Sue, 'and how are the degrees between the problems on the axes assigned?'
'True there are many problems, it's a tool for support,' conceded Jeff. 'They’ve done lots of research using Delphi and other techniques to categorize and prioritize the axes you see here. The stats people have helped enormously, and continue to help refine things.'
As if spotting an opportunity Jeff’s agent announced it was time to close. 'Well I guess health and safety calls. So let’s finish at this point, and resume NVE tomorrow. We’ll look at your assignments this p.m..'
THE END IN SIGHT?
Later that afternoon, in the coffee lounge. 'Here is your personalised virtual record of your experiences today.' Jeff handed a small folder to Sue. 'Your holoCD and E-buk are in the pack. Look after them, there’s more to add - about a teras worth. That's selected highlights from your trip, edited according to your wishes from the questionnaire, with a sequential summary of events, questions and issues. We can fine tune the edit tomorrow pm, if you wish.'
'You both look tired, I erm .. don’t suppose you will want to come back,' Jeff mused. He knew they would really and his grin showed it. 'We just hope it helps you do your job even better, that really is why we’re here.'
Sue was able to smile. 'It is truly amazing, impressive, and technical. And yes it was terrific to learn about Ethel, see her health career as I never imagined I would or could. Still happily confused no doubt, but well cared for. As far as nursing is concerned, well ... in VR I didn’t see any mention of ventilation, warmth, sunlight, cleanliness, and good diet, not to mention rapport, and empathy,' declared Sue, suddenly given to search for the sun outside. 'Just because we can see our patient’s problems - virtually, retrospectively, prospectively, statistically, and not forgetting economically, does that make me care more? Am I a better nurse, and closer to the patients? Patients already wonder 'where have all the nurses gone?'
That was a fitting acronym earlier Jeff - ‘NVE’. Maybe we nurses ‘envy’ other professions who can visualize their profession’s work. It is truly fascinating, absolutely, and we’ll see you tomorrow; but I still think Florence would be most upset,' Sue concluded wistfully.
Jeff had the last word on that, 'Well maybe tomorrow you can ask her yourself?'
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Citation:
Jones, P. (1991-2001) Where Have All the Nurses Gone?,
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