Keywords: Visualization, Visual literacy; Learning styles; Tools; Literature

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Jones, P. (2000) Introducing Visualization:
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Introduction

Visual expression through imagery is a key feature of human thinking and behaviour and has been for countless millennia. When images are absent our brains will seek them out in patterns within naturally occuring phenomena. From pictures in the sand, on cave walls and mythology cast in the sky the representation and projection of the human imagination has always been around us.

As time passes and we enter deeper into the new millennium, the 'visual' assumes ever greater pre-eminence. In our representations of the world, however, things are often not what they seem. Perspective does make a difference. The evidence surrounds us - at least in western culture - as witnessed in our current pre-occupation with space, diagrams, maps, visual effects, and simulations in advertising. Contemporary literature is also onboard as with the novels by Alexander (2000), and Danielewski (2000). Our vocabulary is increasingly being extended with words associated with visual worlds, both actual and virtual. New words are coined, such that now business is not just a matter of 'organisation', but imaginization according to Morgan (1997). Not only is computer literacy de rigueur, but Walker & Chaplin (1997) and other authors claim that visual literacy will be needed in the 21st century and beyond. As Bartram (2004) argues visuality, or ocularcentrism has been linked to dromology - the science of speed and our apparent need to compress time.

"I can see clearly now ...."

Humans are visual creatures. People remember most what they both see and do. Science and technology continue to extend our sensory capabilities - primarily in the 'visual' range. Technology has made what was previously invisible - visible: x-rays, infra-red and other radiation. It is not only our senses that can be extended by technology. Various parts of the body can be replaced. Peter Medawar (1984) refers to these instances as 'exosomatic'. We have, for example, 'exosomatic kidneys' in the form of kidney dialysis machines. The processing and storage capabilities of computers are becoming 'exosomatic brains', with holographic storage devices due to become consumer items circa 2002-3.

The ability to visualise data sets is a constantly expanding application in IT. While these data sets are often 'massive,' our reliance on vision is also apparent in tasks that are not so 'data-bound'. Computer assisted searches of the health care literature reveals a rich cornucopia of 'visually' oriented material:

Everyone it seems is keen to emulate engineers, scientists in their visualization activities. Strange to think how vacuum cleaners have changed in look and design. The evidence of the ease of design, visualization and prototyping are all around. These new vacuums looking like static versions of the robotic forms that will surely replace them, and already in the marketplace. Such is the impact of visual (and digital) culture that cinematographers quickly caught the bug:

COMMUNICATION OF IDEAS, CONCEPTS, RELATIONSHIPS;	see visualization links
EXPLORATION, RESEARCH and DESIGN;
MEDIA;
GENERAL INFORMATION.

Psychiatric and psychology services use guided imagery and 'visualization therapy' to help patients rehearse new behaviours. Change may then be more likely. Lyotard (1988) refers to borderzones. Physical change is a key preoccupation for health professions. Medical imaging (MI) is often used as an example of visualization at its best. MI is now well established with dedicated journals, with new titles emerging. MI is not new and already has quite a history see Shortcliffe (1990) and Tang et al.'s (1999) accounts.

Nursing and visualization - surely not?

After many decades the nursing profession still strives for scientific status. In (1991) Clark appealed for appropriate recognition from the medical profession, declaring that nursing is an 'intellectual activity' and not just a collection of manual tasks, conjoined by knowledge borrowed from other disciplines. Ozbolt & Greaves (1993) stated that nurses be regarded as 'knowledge workers'. If, for sake of argument, it is accepted that nursing has a scientific basis, then it can be assumed that:

The first question is not just how nurses can use visualization (perhaps it is not possible at all), but why? Why should nursing jump onboard this latest bandwagon? Especially in view of the often lack lustre performance of ICT in nursing thus far. A further pause for thought is uncertainty regards the status of visual culture, is it a discipline, is it interdisciplinary (Bal, 2003)? Spence and Tweedie (1998) remind us of a commonly cited reason in education: a Chinese proverb they have extended -

Staying with education Riding & Buckle (1990) stress the importance of studies in learning styles within individualised computer-based learning. Some people are verbalisers, whilst others are imagers. How might learning styles impact on education in nursing and health care, and crucially on the application of ICT in care environments such as ward, health centre, patient's home?

On paper we are essentially constrained to black on white. What other possible cues could health workers use - sound, proximity, position, size, area, volume, movement, colour, and speech? In Database Exploration Using Multidimensional Visualization, Keim & Kriegel (1994) suggest that technology makes other cues possible, but as with visualization the differences in application and data sets may make such comparisons irrelevant? How could these cues be implemented in One possibility is that health workers adopt a set of common icons? Use of the term 'icon', however might then seem to trivialize scientific visualization.

HAVE NURSES BEEN HERE BEFORE?

The links below list some of the PROS and CONS of visualization in nursing.

If you view the above 'pros' link you will find item 7 - the 'possibility of benefits' which is included out of tradition. A tradition within many computer projects of claiming benefits without a proper impact assessment or benefits realisation evaluation. Prediction is never easy, but seriously what can be said overall? Am I guilty of acting out the same tradition? Trying to fit four quadrants into a round hole?

As in many situations it is a combination of several factors that beg us to explore the possibilities. Explorers in other disciplines have already found their own new territories, verdant pastures for the knowledge gatherers. New tools and branches of thought are being founded. In all projects, an orderly progression is needed. A progression that Brian and I do not have the time to pursue.

Explorers in other disciplines have already found their own new territories, providing verdant pastures for the knowledge gatherers. New tools, whole new branches of thought and science are being founded. In all projects an orderly progression is needed. A progression which Brian and I do not have the time or resources to pursue, that does not stop further questions:

What does the literature say?
	What lessons have already been learnt?
What factors are driving health & social care informatics? Where is the emphasis? Clinical practice? Management? Education? Politics? Bureaucracy? Does this promote visualization or negate any potential? Which direction are we headed? Will we see the boundaries before the bump is felt?
	What visual and diagrammatic (cognitive) aids are already employed?
What visual and diagrammatic (cognitive) aids could potentially be employed?
	What research questions need answering? For example, what evidence is there that health care assessment, evaluation and other tasks can benefit from visualization? What do we mean by visualization in this context? Is there a new definition / application here? What are the implications for the profession of nursing and the wider multidisciplinary team?

All of the above points demand consideration, and the links below explore some of the basics and background to technology, plus an introduction to data and information processing. Being an advocate for a dynamic role for visualization in nursing, does not mean that paper has (totally) had its day. We are acutely aware of the power that parallel processing imbues within computing, but Tufte (1997) draws attention to parallelism within prose and asks:

'What are the strategies of visual parallelism? Are there visual analogs to syntactical and rhetorical principles? Analogs to the more subtle aspects of parallelism in language, such as ellipsis and deliberately faulty parallelism?' ( 79 : 1997)

TECHNOLOGY: hard and soft
	DATA / INFORMATION PROCESSING
ASSUMPTIONS underpinning the HCM
	DIAGRAMMATIC TYPES AND REFLECTION
ICT SUPPORTED COLLABORATIVE WORKING (to follow?)	see links
	CONCEPT OF 'SPACES' (to follow?)

© Peter Jones 2000

References

Alexander, L.A. (2000) Intimate Cartographies, Duck Editions.

Bal, M. (2003) Visual essentialism and the object of visual culture, Journal of Visual Culture, 2(1): 5-32.

Bartram, R. (2004) Visuality, Dromology and Time Compression; Paul Virilio’s new ocularcentrism,
Time & Society, 13: 2/3, 285–300.

Chang, M.C., Mondy, J.S., Meredith, J.W., Holcroft, J.W. (1998) Redefining cardiovascular performance during resuscitation: ventricular stroke work, power, and the pressure-volume diagram. J. of Trauma-Injury Infection & Critical Care. 45(3):470-8.

Clark, J. (1991) Nursing: an intellectual activity, BMJ, 303,376-7.

Danielewski, M.Z. (2000) House of Leaves, Anchor.

Endo, E. (1996) Pattern recognition as a nursing intervention with adults with cancer. UNIVERSITY OF MINNESOTA ** PH.D.

Faulkner, A., Regnard, C. (1994) Handling difficult questions in palliative care: a flow diagram. Palliative Medicine. 8(3):245-50.

Ferrario, V.F., Sforta, C., Serrao, G. et al. (1999) Soft tissue facial growth and development as assessed by the three-dimensional computerized mesh diagram analysis. Am. J. of Orthodontics & Dentofacial Orthopedics. 116(2):215-28.

Floyd, J.A. (1999) Designer's corner. The use of metaphor graphics to depict sleep research results, Canadian J. of Nurs. Res. 31(1):73-8.

Heiney, S.P., Darr-Hope, H. (1999) Healing Icons: art support program for patients with cancer. Cancer Practice: a Multidisciplinary J. of Cancer Care. 7(4):183-9.

Hinton, R., Hinton, D. (1999) Practice note. Tactile diagrams for the able undergraduate chemistry student. J. of Visual Impairment & Blindness. 93(7):429-33.

Johnson, D. (1997) Performance improvement, ideas & innovations. How to create a cause and effect diagram. J. of Nurs. Care Quality. 11(6):5-7.

Keim, D.A., Kriegel, H-P. (1994) VisDB: Database Exploration Using Multidimensional Visualisation, IEEE Computer Graphics and Applications, Sept.

Kress, G., van Leeuwen, T. (1996) Reading Images: The Grammar of Visual Design, Routledge, London.

Lancaster, D.R., King, A. (1999) The spider diagram nursing quality report card: bringing all the pieces together. J. of Nurs. Admin. 29(7/8):43-8.

Lepley, C.J. (1999) Affinity maps and relationship diagrams: two tools to enhance performance improvement, J. of Nurs. Care Quality. 13(3):75-85.

Lipkus, I.M., Hollands, J.G. (1999) The visual communication of risk, J. of the Nat. Cancer Inst. (25 Monographs):149-63.

Lyotard, J-F (1988) The Differend: Phrases in Dispute. (translated by Georges Van Den Abbeele) Minneapolis: University of Minnesota Press. (Thanks to the AFT newsgroup for this reference).

Medawar, P. (1984) The Limits of Science, Oxford, OUP.

Morgan, G. (1997) Imaginization, Sage Publications Inc. USA.

Morrow, D.G., Hier, C.M., Menard, W.E., Leirer, V.O. (1998) Icons improve older and younger adults' comprehension of medication information, J. of Gerontology Series B-Psychol. Sciences & Soc. Sciences. 53B(4):240-54.

Nunnelee, J.D. (1996) Decision making in prevention and treatment of arterial leg ulcers: use of patho-flow diagramming. J. of Vascular Nursing. 14(3):72-8.

Ozbolt, J.G., Greaves, J.R. (1993) Clinical Nursing Informatics: developing tools for knowledge workers, Nurs. Clinics of North America, 28 (2),407-425.

Pfeifer, A., Beard, M.T. (1997) Toward a theory of imagery in elderly cancer survivors. J. of Theory Construction & Testing. 1(1):12-7.

Riding, R.J., Buckle, C.F. (1990) The computer determination of learning styles as an aid to individualised computer-based learning, Assessment Research Unit, Training Agency, Univ. of Birmingham (UK), chap 1.

Shamansky, S.L., Graham, K.Y. (1999) The Venn diagram: a metaphor for life. Public Health Nurs. 16(1):1-2.

Shortcliffe, E.H. (et al.) Ed. (1990) A History of Medical Informatics, Wokingham, Addison-Wesley Publishing Co.

Spence, R., Tweedie, L. (1998) The Attribute Explorer: information synthesis via exploration, Imperial College, London, UK Interacting with Computers 11, 137–146.

Tang, L.H.Y., Hanka, R., Ip, H.H.S. (1999) A review of intelligent content-based indexing and browsing of medical images, Health Informatics J., 5(1):40-9.

Tufte, E.R. (1997) Visual Explanations, Graphics Press, Conn.

Turner, D.G., Berger, N., Weiland, A.P., Jordan, M.H. (1996) Washington burn watch. The revised burn diagram and its effect on diagnosis-related group coding, J. of Burn Care & Rehab., 17(2):169-74.

Vergani, C., Corsi, M., Bezze, M., Bavazzano, A., Vecchiato, T. (2004) A polar diagram for comprehensive geriatric assessment, Arch. Gerontol. Geriatr. 38, 139–144.

Walker, J., Chaplin, S. (1997) Visual Culture, Manchester Univ. Press, 111.

Zielstorff, R.D., Tronni, C., Basque, J., et al. (1998) Mapping nursing diagnosis nomenclatures for coordinated care. Image - J. of Nurs. Scholarship. 30(4):369-73.

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