Person centred care, wormholes, pesterers and care domains (ii)

Person centred care, wormholes, pesterers and care domains (i)

Mentor: Sorry my friend where were we up to?

Student: I am still puzzled as to how we can define and represent person centered care? Where does person centered care fit in h2cm (Hodges' health career model)?

The INDIVIDUAL-GROUP vertical axis places the person, the individual - at the top of the model. That could be a positive if we are thinking hierarchically, but shouldn't a model that is situated AND person centred be explicit and put the person at the center?

Mentor: This is a good question and you are right to ask it. As our previous discussions have illustrated our models are idealised and yet they should reflect the real world and experiences they seek to model and re-present for us:

Student: but in this case....?

Mentor: Well, not so quick...

As we noted the World's governments get the citizenry they deserve and vice-versa. If peace, political engagement, legitimate government and contentment are not a given but have to be earned then is person centred care any different?

Student: So, you are saying that peace, being a citizen, and mm... well-being I suppose are in a sense similar to person centered care?

Mentor: Perhaps?

Student: That seems quite a leap.

Mentor: Well your question prompts exercise - a certain gymnastics even - and with that a daily requirement we'll save this point for another time.

For now though... I know we don't necessarily need a precise definition of person centered care at the moment, but humour me and see what you can come up with in terms of this model of care. As you have mentioned it includes the INDIVIDUAL, the GROUP. And with the interpersonal and science domains the person's mind and body are literally in the frame.

Student: Well unless we are talking medical emergency then person centered care is about ensuring the individual is taken into account across all the domains of care.

That is - intra-interpersonal, physically - through the sciences, socially and politically. 

Oh - and spiritually too of course.

Mentor: So person centered or being person centered concerns domains of care?

Student: No. It's the content that matters. Take the interpersonal and myself as an example - what are my beliefs, previous experiences, writing skills and interests, my mood, disposition and attitude towards others. That only scratches the surface.

Mentor: I see. Can you go on from there...?

Student: Well I suppose each domain is visited according to various cues - and this is where context and situation come in. These supply the cues. They determine what is significant, what counts as information. For experienced nurses and health care practitioners this travel within and across the care domains comes as second nature.

Mm... I suspect that even if someone was not using h2cm explicitly their cognitive - conceptual movement could still be traced through the model, like passes on a football pitch.

Mentor: Very poetic! So if these care domains are being reflected upon does that mean person centered care is a consequence?

Student: Well I suppose it could if you take your mention of 'reflection' literally. Yes, picture the patient - the person - in the center of the h2cm matrix. We might even argue that our reflections place them there? Within the model what is the position of the person? If our deliberations could be measured - and practically that would be quite a task given patient engagement and dialogue - then is there an average across the domains? And is that the center - hence person centered?

Mentor: An interesting idea. And yet as you questioned initially the INDIVIDUAL in the model is at the top, at the top of an irregular continuum, so...?

Nursing: magnetic Force 5

Back in 2009 I came across a post - Nurse magnets crucial for recruitment and retention about the 14 Forces of Magnetism:

In 1983, the American Academy of Nursing conducted a survey of 163 hospitals to learn why some hospitals attracted and retained well-qualified nurses who were devoted to quality patient care.

The 14 Forces are listed and described by the ANCC. The forces themselves include:

• Force 1 Quality of Nursing Leadership
• Force 2 Organizational Structure
• Force 3 Management Style
• Force 4 Personnel Policies and Programs
• Force 5 Professional Models of Care
• Force 6 Quality of Care
• Force 7 Quality Improvement
• Force 8 Consultation and Resources
• Force 9 Autonomy
• Force 10 Community and the Hospital
• Force 11 Nurses as Teachers
• Force 12 Image of Nursing
• Force 13 Interdisciplinary Relationships
• Force 14 Professional Development

The professional, organizational, and political (policy) emphasis of the 14 forces is obvious and becomes clear when each is weighed in terms of where it sits within the domains of h2cm.

Try it as an exercise. ...

Recruitment is ALL about magnetism.

If you are unsure, ask a magnet about the meaning of retention.

Demographics are already applying pressure upon these forces of magnetism. Not just when referred to explicitly in the USA within organizational media; but globally. Demographics is another magnet - it approaches with increasing force.

From here in the UK (and readers elsewhere) we have to exercise care when models are mentioned. While the theorists and philosopher's of nursing nail their definitions to the mast (h2cm?) there remains a models muddle, not just in the variety of models of care, but in the levels at which they operate. This is not a criticism, it's an observation - consider Force 5:

Force 5: Professional Models of Care
There are models of care that give nurses the responsibility and authority for the provision of direct patient care. Nurses are accountable for their own practice as well as the coordination of care. The models of care (i.e., primary nursing, case management, family-centered, district, and holistic) provide for the continuity of care across the continuum. The models take into consideration patients’ unique needs and provide skilled nurses and adequate resources to accomplish desired outcomes.

In the US in particular 'models of care' (moc) often refer to finance and accountability of costs (the market process), in the UK moc might refer to commissioning. In Force 5 the addition of 'Professional' (as the original author's no doubt recognized) is crucial. If you repeat the above exercise, plotting Force 5 on the Health Care Domains Model then you see how Force 5 works for nursing and remains to this day a great achievement as a yardstick for quality, assurance and retentive power.

In the almost 30 years since the research on the 14 Forces, I do wonder though if there is a need to imbue the following with magnetic properties:

• person-centred care;
• self-care;
• carers and public engagement;
• prevention;
• public (mental) health
• and informatics?

Yes, many of the above can be assumed to lie within the existing Forces 1-14. Health and social care are not static. Nursing has much to contend with from the level of the individual practitioner through to the group within an organization. The 14 Forces of Magnetism are well established in the USA and deservedly so, they clearly deliver.

In the political and economical heat of an economic recession, however; magnets may reach their particular^* Curie point. Then they cease to work.

The constant bangs and knocks of change, the incessant hammering of party politics and the 'market' on the door of "high quality nursing care" can also take its toll on magnetism.

Nursing needs to take care.

Related post on Healthcare IT News:

Top 10 trends for 2011 include IT, new care models

*OK it should be constant, but like our patients these magnets are not all the same - they have varying levels of vulnerability.

To follow some definitions from an olde book ...

Recipe II: Holistic care - Care pebble overhere!

...

WouldBeUser: Well there's no shortage of pebbles, the referrals come thick and fast.

ActualUser: That's why reflecting on that particular pebble is important, turning it - them, their situation over. Asking yourself is there anything I and the team have missed?

WouldBeUser: OK, the beach is still full of them!

ActualUser: Is it the pebble you are trying to see?

WouldBeUser: Ah, of course! Individualised care?

ActualUser: That's right. Nursing, health, social care and in fact good governance everywhere is about seeing the person. Sometimes it isn't easy; but if you pick that person out then you can count the rewards as you would the pebbles on the beach ...

Original image sources - see Recipe I

Recipe: Holistic care - Care pebble turnover*

WouldBeUser: How can you sum up use of the health career - care domains - model?

ActualUser: Well it's a bit like you are picking and throwing some pebbles on the care plan or game board.

WouldBeUser: What - as simple as that!

ActualUser: Yes, but - NEVER underestimate the value of turning each of those pebbles over and reflecting, sharing...

*Also great for a game of nudge - nudge.

Original image sources:

http://imagecache.artistrising.com/artwork/lrg//4/417/7CV9000A.jpg
http://www.crglass.ca/images/dark%20green%20pebbles.jpg
http://www.crglass.ca/images/dark%20blue%20pebbles.jpg
http://www.crglass.ca/images/red%20pebbles.jpg

Buller and Butterworth: Skilled nursing practice - four domains?

The health care domains model identifies four domains within health and social care and medicine. What evidence is there to support the model's inclusion of:

INTERPERSONAL : SCIENCES

SOCIOLOGY : POLITICAL

- plus the spiritual within and without? Steve Buller and Tony Butterworth undertook a ethnographic study in 2001 'Skilled nursing practice - a qualitative study of the elements of nursing'. With skilled nursing practice at the center (Fig. 5.) they identified:

relating and communicating	doing the job
being professional	managing and facilitating

There is some overlap, reflection arises in relating and communicating and doing the job. Overall however there is a definite correspondence between these domains and those within h2cm - the health care domains conceptual framework. I have equated being professional with the SOCIOLOGY domain as for the authors this includes being with patients, conveying confidence, handling situations, being informed. Managing and facilitating is undoubtedly POLITICAL with supervising, auditing, making sure things get done. Doing the job - is based upon planning, informing, assessing, intervening, and being confident (with equipment, procedures, manual dexterity..?).

Having been thinking and writing about h2cm for many years it is a shame that other models have benefitted from funding and gain "ward and community (research) cred" while here evidence is retrofitted. Looking at the paper just in the decade since submission and publication I wonder which elements remain local, and where other elements of the skills base (care concepts) have migrated to ethnographically?

Steve Buller, Tony Butterworth (2001) Skilled nursing practice — a qualitative study of the elements of nursing. Int. J. of Nursing Studies. 38, 4, 405-417.

Care origin(s) and open access #OAW2010

The most striking and ubiquitous presence in the health career model is its basic diagrammatic form. The image at left provides some mathematical additions and there at the center is the origin.

In this respect the model (literally) draws our attention to the identification of the care problems, constraints, strengths, solutions that affect the individual with whom we are engaged. We are immediately aware that there is inevitably more than one aspect to consider.

To save repetition I am only going to refer to problems. So, the model's form highlights that there is no single origin of problems, but many. At some time a problem, for example physical, may become the priority. Then the SCIENCES domain is critical. Deprivation of liberty concerns may split the priority creating tension across the INTER-intraPERSONAL and POLITICAL domains.

As priorities are dealt with there needs to be a return to the -

origin.

The question is asked: in which care domains do the problems lie? We call this re-assessment and evaluation.

In Open Access Week the health care model is also 'open access'. Not just in terms of being a free, accessible resource available to all, but being discipline agnostic, neutral and applicable across cultures and ethnic groups. The model is also open in terms of mindset. The users of h2cm provide that and as they do open* and origin-al care unique to the individual has a chance to follow.

*Open care? Mmm...


Image source: origin - http://en.wikipedia.org/wiki/File:Coordinate_with_Origin.svg

Naivety [I] ever unfolding : ever present - SCIENCES

naivety [naɪˈiːvtɪ], naiveté, naïveté [ˌnɑːiːvˈteɪ]n pl -ties, -tés

1. the state or quality of being naive; ingenuousness; simplicity

2. a naive act or statement

My source:
http://www.thefreedictionary.com/naivety

There are times when we are all naive. It can be so embarrassing! When you realise, or more severely are made aware by others the abrupt learning is suddenly resolved. Within the bounds of the health career model, naivety can be found and is expressed in so many ways.

Hodges' model may appear naive in its simplicity, but behind that simplicity there are several assumptions. When you act as scribe, reader or doer you exercise the model's structure. You potentially demonstrate several levels of literacy.

If the health career model can represent most 'everything', then naivety should be no problem. So, if we visit each of the care domains in turn what can we find?

SCIENCES

I came across a post: 'We are all naive scientists' on The Financial Philosopher blog which includes this quote:

"It is clear, then, that the idea of a fixed method, or a fixed theory of rationality, rests on too naive a view of man and his social surroundings." ~ Paul Feyerabend

Regularly, I ask myself if I am naive in this particular domain. Am I right to assume that there are questions in nursing that can be answered (or at least reflected upon) using Hodges' model? Furthermore, can this use, this application be demonstrated in a scientific (evidenced) way?

Does experience of programming in BBC Basic as an enthusiast really help equip me now to get to grips with PHP, using Drupal and even Ruby?

Is information (and informatics) really the all encompassing Swiss army knife of a concept I take it to be?

The most extreme naivety here is not mine, however; it is as Feyerabend suggests the one that is in diagonal opposition. It is the scientific naivety of the masses in the social domain. Is this ignorance? In some cases, yes. But the tabloid (gutter) press shouts aloud when science gets it wrong; or, more accurately industrial porcesses based on science totally mess up.

The masses are not divorced from science. True, there was (still is?) a promised intimate relationship borne of equality and egalitarian ideals (education), but this naivety matures in real (social) time also known as life-chances. Its cost is not just red-faced, but illiteracy and exclusion at a time when literacy, inclusion and engagement are paramount.

Drupal musings 13: Packaged care and modules

Although I do not need to sit at the front for presentations anymore, I did so at Drupalcon as the electricity plugs were few and forward. There was a bonus. Being in the right place... I picked up a free book c/o Packt Publishing who were among the exhibitors and valued sponsors. The book is Michael Peacock's Social Networking (don't panic I'm not going to review it!). Since returning from Copenhagen I've been using Drupal 6 and 7 on a daily basis. Checking just what some of the key modules, such as Taxonomy, Taxonomy Manager, and Groups have to offer. What are the configuration options and how well do modules integrate?

In the book Michael lists the Drupal modules he relies on to create a site worthy of the book's title. He explains that many modules are themselves 'packaged' for example - the Activity module:

Activity: Activity
Activity: Activity history
Activity: Comment activity
Activity: Node activity
Activity: OG# activity (#organic groups) p.140

This highlights the multifunctional capability of modules which leads me to wonder* about what functionality might be found in future modules:

Intrapersonal: Communication Intrapersonal: Mood Intrapersonal: Cognition Intrapersonal: Diagnosis Intrapersonal: Interests Intrapersonal: Risk Intrapersonal: Skills-Education	Sciences: Observations Sciences: Physical attributes Sciences: Mobility Sciences: Nutrition Sciences: Diagnosis Sciences: Physical safety
Sociology: Relationships Sociology: Ethnicity Sociology: Interests Sociology: Religion Sociology: Carer assessment	Political: Marital status Political: Employment Political: Benefits-Welfare Political: Capacity Political: Autonomy Political: Mental Health Act status

Further news:
The new PC is ordered 10-12 days until its arrival. Yes, I could go DIY, but I'm busy.

This Saturday evening I will have some 4-5 hours with the client of the basic Drupal 6 site. Very much looking forward to that. Must remember KISS!

*Not necessarily an actual proposal!

Paper: Patel et al. (2009) Clinical complexity and medical education

The following item about a paper from last year was posted by Rakesh Biswas on the COMPLEXITY-PRIMARY-CARE list. After Rakesh's comments I have included a quotation.

The paper in question by Patel, et al. will be an important reference for me, even though the definition of domain and discipline remains problematic. (A glossary for the health career model will follow on the new site.)

Suddenly, the passing of time is also clear given that:

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

- appeared twenty years ago. Ten years ago I cited Shortcliffe et al..

Twenty years! How long is that in technology / internet terms?

The bold text below is my emphasis:

From: Rakesh Biswas
To: COMPLEXITY-PRIMARY-CARE@JISCMAIL.AC.UK
Sent: Thu, 12 August, 2010 16:41:06
Subject: Clinical complexity and medical education

As our society progresses in the accumulation of knowledge and as the complexity of this knowledge increases, it becomes more important to determine how to structure education to provide individuals with the most comprehensive base of knowledge without sacrificing either depth and complexity or broadness of material.

Human beings have an extraordinary capacity for storing large volumes of organized information in memory. How does one apply such detailed knowledge to practical, real-world problems and situations?

What is the optimal mode of learning that will promote flexibility and transfer of general knowledge across domains during problem-solving?

For more, see the article by Dr Patel whose focus area is Medical Cognition (how doctors think and develop their so called expertise).

Regards,
Rakesh

Here is a quote from the paper:

Much of the early research in the study of reasoning in domains such as medicine was carried out in laboratory or experimental settings. There has been a shift in more recent years toward examining cognitive issues in naturalistic medical settings, such as medical teams in intensive care units [2], anesthesiologists working in surgery[89], nurses providing emergency telephone triage [90], and reasoning with technology by patients [91] in the health care system. This research was informed by work in the area of dynamic decision-making [92], complex problem-solving [93], human factors [94,95], and cognitive engineering [44]. Naturalistic studies reshaped researchers’ views of human thinking, as expressed in ‘‘situativity” theory’s terms (as described in Section 2.1.4) [23–26], by shifting the onus of cognition from being the unique province of the individual to being distributed across social and technological contexts. p.186.

Whilst as Rakesh points out Dr. Patel's focus is medical cognition, then through the health career model it would appear my interest is nursing cognition. As per the legacy of models of nursing - which did recognize the patient through the concept of patiency (Stevens, 1979) - we realise that now all disciplines must demand much more of their respective models in the 21st century.

Patel, V.L., et al. (2009) Cognitive and learning sciences in biomedical and health instructional design: A review with lessons for biomedical informatics education, Journal of Biomedical Informatics, 42, 176–197.
doi:10.1016/j.jbi.2008.12.002

Stevens, B.J. (1979) Nursing Theory: Analysis, Application, Evaluation. Boston: Little, Brown and Company.

From: Harvard Business Review - The Four Phases of Design Thinking

I came across the following post on the Harvard Business Review Blog Network - The Conversation:

10:54 AM Thursday July 29, 2010
by Warren Berger

What can people in business learn from studying the ways successful designers solve problems and innovate? On the most basic level, they can learn to question, care, connect, and commit — four of the most important things successful designers do to achieve significant breakthroughs.

Having studied more than a hundred top designers in various fields over the past couple of years (while doing research for a book), I found that there were a few shared behaviors that seemed to be almost second nature to many designers. And these ingrained habits were intrinsically linked to the designer's ability to bring original ideas into the world as successful innovations. All of which suggests that they merit a closer look.

You can read the whole of Warren's original post, while below I have taken his focus concepts CONNECT, CARE, COMMIT and QUESTION and associated them to the care (knowledge) domains of Hodges' model. Following that there is a rationale. ...

connect	question
care	commit

Connect:Intrapersonal
Placed in the intra-interpersonal domain this is the domain of concepts, thoughts, ideas, creativity and innovation. This is the essence of Warren's reference to 'connect' -

Designers, I discovered, have a knack for synthesizing--for taking existing elements or ideas and mashing them together in fresh new ways.

The INTERPERSONAL links page also highlights other conceptual 'inhabitants' here; in particular knowledge management, the semantic web and psychology. If analysis and reduction is the outcome of the hard sciences, then here as Warren writes is synthesis, integration and invention. We can see how self-belief is critical to many innovators who pursue their dreams regardless of rebuffs by the establishment, to whom - within the health career model - they are also diametrically opposed.

Question:Sciences
The ability to question lie at the heart of human activity, and although thought and mind are represented in the interpersonal domain, questions also exemplify the output of human reasoning powers in the SCIENCES. Evidence based care depends on an ongoing process-ion of questions that drive research. Problem solving with its iterative sequence of assess (question), plan, action, evaluation (question). The health career model reminds us though of the need to consider not only quantity, logic and objective measures, but the role of qualitative research and methods.

Care:Sociology
Seeing Warren's inclusion of 'care' drew me to his post. Here he concludes:

Focus groups and questionnaires don't cut it; designers know that you must care enough to actually be present in people's lives.

Health and (social!) care are social activities. Our students are socialised into the professions and disciplines as they pursue their careers. Our work depends on the effectiveness of human communication and relationships. You can read about 'counselling' and only get so far; ultimately health care is experiential. It is something to be practised.

Commit:POLITICAL
Warren deals with the way designer's view risk and committing early to an idea and the project that might follow. For me 'commit' and being committed has explicit political - power - connotations. So, Warren's reference to commit in the sense of producing a model or prototype and working through problems can be extended. Invention and design may be cognitive pursuits, but they are non-trivial in that they must ultimately and literally be negotiated. Being able to 'commit' needs to be sanctioned. Individuals need to be empowered, or recognise when to either proceed or seek advice and guidance. Furthermore, Warren notes:

The designer's ability to "fail forward" is a particularly valuable quality in times of dynamic change. Today, many companies find themselves operating in a test-and-learn business environment that requires rapid prototyping. (?)

Perhaps the recognition in health policy of the need to balance negative and positive risk taking, self-care and personalised budgets can also be discerned in the above?

Acknowledgement:
Thanks to Warren Berger and HBR

The cost of anholistic care

Being 'holistic' in care delivery can seem anachronistic, paying homage to new age thinking and practices. Paradoxically, being holistic in nursing can also mimic an admin exercise that amounts to ticking the boxes. So for Hodges' model - have you visited all the care domains?

• INTERPERSONAL care ✓
• POLITICAL care ✓
• PHYSICAL care ✓
• SOCIAL care ✓

Advanced discharge planning is many things:

• idealised care;
• standardised care;
  
• evidence of policy, targets;
• sign posting for the care pathway;
• an essential care aspiration that emphasizes the individual's strengths and resources.

As Wimbledon once again reaches its climax we observe that a fast serve needs to be prepared for a fast return of serve.

Last month 23 June, 2010 The Guardian, Society Guardian featured The high cost of return:

Hospitals could lose up to £1.5bn of NHS funding a year because of the government's decision to penalise those where patients return within 30 days of being treated. That is the conclusion of research conducted by health analysts Dr Foster into the potential impact of the tough new policy. It warns that NHS trusts face large potential losses, the biggest could reach £28.7m, as a result of the new approach. In all, 146 acute, specialist and mental health trusts could lose out. Denis Campbell, p.3.

Apparently -

Andrew Lansley wants to force the NHS to provide better care in hospitals and mental health establishments, to keep treating patients there until they are fit to leave and to work more closely with community-based healthcare professionals, such as GPs and district nurses, to ensure sick people receive more help with their convalescence after discharge and so are less likely to return to hospital. "Making hospitals responsible for a patient's ongoing care after discharge will create more joined-up working between hospitals and community services and may be supported by the developments in re-ablement and post-discharge support," he says.

I hope in reading the above you have a sense of my frustration in that the health career model can encourage and support timely reflection that can help achieve holistic, integrated - coherent care.

If the model was shared
- a common resource -
across disciplines and available to patients and carers
then the potential benefits (and savings?) are even greater.

Care ecology

Webster’s dictionary defines ecology as:

".. the totality or pattern of relations between organisms and their environment."

In health and social care there are several environments:

• cognitive
• social
• physical
• political
• [and spiritual]

In this sense then Hodges' model provides a much needed care ecology:

An ecology not only for* care (disposition?)

- but an ecology to* care (direction?).

That is as something to protect given its inherent inclusiveness, balance and holism - an ecology within which we can also check on the health of our values.

In being focused on life - as an ecology - the model can also encompass the end of life.

*Michael Serres writes on the role of prepositions:

Conner, S. (2008) Wherever: The Ecstasies of Michel Serres, Accessed 19 June 2010.

Jones, P. (2007) Language to Care, Accessed 19 June 2010.

Michael Serres: messengers - a Blog

Comment: session at Beyond These Walls - Public Engagement Colloquium

I am of course really pleased that Prof. George Kernohan employed h2cm in his presentation last month - Beyond These Walls - Public Engagement Colloquium which I posted on W2tQ.

Considering his abstract I have added some observations below that I hope will further highlight the model's potential utility in this and other areas.

To begin George is quite right to describe the model as -

'a relatively simple way to think about and summarise the variety of engagement types.'

This explains the model's use as a student resource, a foundational framework on which to superimpose their learning and map placement and professional development experiences. As a learning activity reflection is greatly concerned with the student's accounts of engagement with patients, colleagues, carers and the public at large. This also flags up the belief that the model has some generic educational purposes in health and beyond with patients, carers and the public.

The model should not however be restricted to simple representations and applications. Granted the safety, efficacy and value of the model remain to be proven, but hopefully the directions indicated here on W2tQ and in publications to date are worthy of further exploration? More complex - lifelong learning - uses of the model might include:

• case formulation
• psychological therapy formulation (CBT, family)
• self-directed care planning and budgeting (sign-posting)
• complex systems in health care
• policy and politics in health care
• reflection: students, client life story work
  
• integrating care recording
• and clearly public engagment in many contexts; research, management and service development.
  

I am adding my (italicised) comments to Prof. Kernohan's original abstract below:

The first quadrant [SCIENCES] deals with scientific response to individual signs and symptoms: where engagement aims to ensure that people comply with the healthcare intervention: engagement is about informing the patient and their informal carer about their physical needs and responses.

People comply when they understand treatments and this understanding needs to be demonstrated. There has been much emphasis on concordance, but this has to be earned as Prof. K. indicates.

The second quadrant [POLITICAL] deals with mechanistic and group activity: for example political interventions to agree rules, policy and systems. Engagement here refers to members of groups working under a specific governance system or approach– activists and unions lobby for change, in this care domain. Arrangements for protection of vulnerable people are set through engagement here. Ethical issues guide the group mechanistic activities.

The past couple of years has seen a whole new group of people acting in this domain. The Mental Capacity Act has resulted in various protections for individuals who are assessed as lacking mental capacity. Whilst this is quite specialist and the province of secondary care and social services, the public will increasingly be exposed to vulnerable adults in their community, on their street. (I saw a gent walk past last night - to be collected by a care worker and taken back to the near-by care home. There was some resistance as they reached the corner. Deprivation of liberty and best interest sprang to mind. ...)

There are numerous other examples: membership of the public in Foundation Trusts, consultation processes on service locations, the provision of information resources for the public.

Another critical policy factor here is QUALITY, how this is measured and the public engaged in those measures and their EVALUATION.

A hybrid approach WILL be needed. A single measure is insufficient and within h2cm inevitably skewed.

Thirdly [SOCIOLOGY], there are more humanistic aspects of care: speech, thought, narrative and free text: stories contribute to group actions. Here we have the social and cultural components to remind us that engagement must work in a social context.

I tend to ground speech and thought in the interpersonal domain (related to cognition) as the primary focus of nursing (health and social care) is the individual. Although communication (society) is impossible without thought and speech and there is a special link here in that the individual cannot acquire appropriate thought and speech without being socialised.

Stories have a definite home in this care domain. Stories are the foundation of what people share, who we are, heritage. Stories differentiate familiars and strangers - stories old and new. Narrative medicine is here, right now. Significantly, the rise of science is in diagonal opposition to the domain of stories.

The final domain [INTER-intraPERSONAL] emphasizes the role of the individual in needing tailor-made care, requiring dignity and respect. Here lies a more holistic type of care and is more ‘mind’ than ‘body’ where interpersonal aspects of engagement are more person-centred.

This domain and the proximity of the 'individual' axis is the focus of nursing care. The rationale for individualised, personalised, person-centred, client-centred care is found here. We need to cross the individual axis repeatedly in order to achieve holistic care. There is no single destination. This journey is never a 'single' in two senses: neither one-way, nor travelled alone hence George's objective in public engagement.

Across all four care domains, public engagement is a key sustaining action to make the model meaningful but also to provide some reassurance that engagement although complex and varied, can be managed in a logical way to enhance care.

I can see what George means by stating that engagement can be managed in a logical way.

Logic's extent varies across the care domains of Hodges' model; from the logical affirmation and assurance that underpins evidence based interventions to the decision algorithms that inform NHS Direct. There is also a need for recourse to several forms of logic as the model is traversed and negotiated. Folk theory, dreams, the chaos of elections and economic uncertainty, and the public's sense of demographic trends also have their place.

I understand that Prof. Kernohan's slides will be posted on the event website in due course.

Many thanks to Professor Kernohan for his recognition and publicizing of the health career model.

Image source:
Gogeometry.com - http://www.gogeometry.com/problem/p076_square_circle_area.htm

Hodges' model: subject of a session at Beyond These Walls - Public Engagement Colloquium

Hodges' model found a place in a session at:

Beyond These Walls - Public Engagement Colloquium
Faculty of Life and Health Sciences
22nd April 2010 at the Ross Park Hotel, Kells

Theoretical review of public engagement in Nursing: Abstract

by George Kernohan, Professor of Health Research Nursing, University of Ulster

Nursing & health professional have wide roles in care of people in need, in sickness and in health and in supporting their informal carers. These roles, by necessity involve people in various ways: in this paper Hodges Health Career Model (Jones, 2009) is used to provide a framework to underpin public engagement in nursing. The model provides a relatively simple way to think about and summarise the variety of engagement types. It comprises two lines and eight words which appear to provide a graph with two axes. The vertical axis involves the recipients of care: individuals and groups, the other involves the care provider and what they do: from mechanistic to humanistic.

The first quadrant [SCIENCES] deals with scientific response to individual signs and symptoms: where engagement aims to ensure that people comply with the healthcare intervention: engagement is about informing the patient and their informal carer about their physical needs and responses.

The second quadrant [POLITICAL] deals with mechanistic and group activity: for example political interventions to agree rules, policy and systems. Engagement here refers to members of groups working under a specific governance system or approach– activists and unions lobby for change, in this care domain. Arrangements for protection of vulnerable people are set through engagement here. Ethical issues guide the group mechanistic activities.

Thirdly [SOCIOLOGY], there are more humanistic aspects of care: speech, thought, narrative and free text: stories contribute to group actions. Here we have the social and cultural components to remind us that engagement must work in a social context.

The final domain [INTER-intraPERSONAL] emphasises the role of the individual in needing tailor-made care, requiring dignity and respect. Here lies a more holistic type of care and is more ‘mind’ than ‘body’ where interpersonal aspects of engagement are more person-centred.

Across all four care domains, public engagement is a key sustaining action to make the model meaningful but also to provide some reassurance that engagement although complex and varied, can be managed in a logical way to enhance care.

Jones, P. Hodges Health Career - Care Domains – Model. 2009.
http://www.p-jones.demon.co.uk/ accessed 25/03/2010

Chambers, R. Involving Patients and the Public. How to do it better. 2000. Radcliffe, Oxon

Related links:

Kernohan, G. Theoretical review of public engagement in Nursing. Proc 1^st Public Engagement Colloquium, Kells, Co Antrim, 22 April.
http://www.ulster.ac.uk/scienceinsociety/beyondthesewalls.pdf

Science in Society

Musings in the nursing domain (specific language)

It is one giant leap from the humanistic world of nursing, health and social care to the m(a-e)chismo of information technology. It is no Earth-bound chasm that greets us in considering the vaguest possibility that nursing could ever be captured, distilled and represented in a domain specific language (DSL). Given the full title of Hodges' model my attraction to DSLs should be obvious, but how realistic is this fascination?

Here are some links to definitions / resources on DSLs:

• Michael Fowler
• DSL Bibliography
• WikiPedia

I am not advocating DSLs as a real time clinical software application, there is neither time here, nor on the wards. Since the sky above is clear blue with not a contrail in sight I am indulging in a little blue sky thinking, a reverie...

Nursing already has its concept analysis, but taken at face value this says nothing about domains as per h2cm (other than the context / application is nursing). To avoid confusion with career in the job-work sense, I have emphasized the notion of domains. By this I mean a partition of specific knowledge about a discipline or subject. This disciplinary focus or subject is often the province of expert practitioners. My forte then in Hodges' model are the INTERPERSONAL and SOCIAL care domains. This is my rationale for the musings here, as all experts were learners once upon a time, and are still as lifelong learners. It is an educational application that I have in mind.

I have come across a paper by Reinhartz-Berger, who describes the movement - Towards automatization of domain modeling. The author refers to domains artifacts and domain analysis:
(I have removed the reference numbers and inserted from prev para*)

A domain in this context [Domain engineering, also known as software product line engineering]* can be defined as a set of applications that use common concepts to describe requirements, problems, capabilities, and solutions. Domain artifacts are built and reused through domain analysis, which identifies the domains and captures their ontology to assist and guide system developers with particular applications in those domains. Despite the rapid growth of technologies and technical solutions, domain analysis models usually remain valid longer than domain designs and implementations, potentially justifying the cost and effort required for their development. Domain analysis artifacts may also serve as the basis for defining Domain-Specific Languages (DSL). Reinhartz-Berger (2010), p.491.

As the previous post - Reading the signs... Idealised Care - amongst several revealed, the domains within the health career model are broad to say the least. So broad that from the INDIVIDUAL-GROUP axis the left-hand margin of the INTRAPERSONAL-SOCIOLOGY^# care domains are but distant horizons (with no curvature in-sight). It's no surprise that I keep wondering about how to get a grasp on that 'space', for reasons of a website, a potential community of explorers, educational objectives and sheer enthusiasm for trying to mix IT up. Reinhartz-Berger continues:

Several domain analysis methods have been proposed over the years. However, they all can be criticized as making the domain engineer alone responsible for developing correct, complete, and consistent domain analysis artifacts. Since domains may cover broad areas and are usually understood only during the development process, creating domain models can be a very demanding task. It requires expertise in the domain, reaching a very high level of abstraction, and providing flexible, yet formal, artifacts. Reinhartz-Berger (2010), p.491.

Also in the literature Chavarriaga and Macías (2009) highlight two approaches that are the focus more generally to help get a grip and the big wide world of knowledge: The Semantic Web and Web 2.0.:

... However, in spite of its semantic power, one of the main underlying problems with this [semantic] paradigm is the explicit representation and visualization of information, mainly focused on ontologies and the complex relationships that these code. This has made the Semantic Web inaccessible and unmanageable by most designers that are not expert on ontological representations and languages, but on domain specific applications and creative design.
On the contrary, the Web 2.0 paradigm provides a rather pragmatic vision. It is based on the use of wikis, folksonomies and protocols like SOAP, mainly intended to the automatic management of services and the collaborative maintenance of (mainly) syntactic knowledge-based information. Moreover, Web 2.0 can be considered an end-user paradigm. ... Chavarriaga and Macías (2009), p.1329.

The Semantic Web, Web 2.0 will (at some point) figure in the new site. A folksonomy can be quite broad by definition, as there is no strict control on the definition of terms. As to DSLs in Hodges' model, there we have four VERY broad domains. Exactly how domain analysis proceeds and what domain artifacts might emerge from this model would no doubt depend on reducing each of the domains, sub-dividing, being more specific.

If nothing else at present the health career model is a hybrid cognitive domain specific language.

References: (my source: Science Direct)

Iris Reinhartz-Berger (2010) Towards automatization of domain modeling, Data & Knowledge Engineering, Volume 69, Issue 5, May 2010, Pages 491-515. doi:10.1016/j.datak.2010.01.002

Enrique Chavarriaga, José A. Macías (2009) A model-driven approach to building modern Semantic Web-Based User Interfaces, Advances in Engineering Software, Volume 40, Issue 12, December 2009, Pages 1329-1334. doi:10.1016/j.advengsoft.2009.01.016

Reading the signs - Idealised Care

With the axes of the health career model labelled and the care domains - that fall between - identified, what can we read into and from the health career - care domains - model?

What basics of care and caring can we find there, what assumptions can we jump upon?

Here is a list ... (which also illustrates how the model grows with the learner) :)

• Health, well-being and social care are not declared in the face of the model, this suggests the model is high-level - generic.
  
• Health care (here) has at least seven disciplinary degrees of freedom:


• Sciences (biology, physics, chemistry)
  
• Politics
• Psychology
• Sociology
• Spirituality

• Health and social care theory and practices are reductive.
• Health care involves the traversal of space - distance.
  
• Health and social care has the potential to be depersonalising and alienating.
• Health and social care is simple and complex.
• The environment is inherent within the model in its varied forms.
• There is a moment of imbalance within the INDIVIDUAL - GROUP.
  
• Context is essential as a means to situate care (co-ordinate in an 'x','y' sense).
• The means is provided to situate the care context in a person-centred way.
• This model provides a template for personal and group reflection (shallow or deep).
  
• The model is open in terms of the final content, the content as expressed in care approach, philosophy, discipline, description (concepts, problems, priorities, strengths, a 'mash-up') is not dictated.
  
• In acknowledging the existence and primacy of the individual (located at the top so - must be important), the model provides a (potential) focus and vehicle for individualised, personalised, person-centred care.
• Whilst individualised care is at the center of care theory, practice and management, it cannot be defined purely by virtue of the INDIVIDUAL-group axis and the claim of an associated INTRA-INTERPERSONAL care domain.
• The individual must also be considered as a POLITICAL entity, a citizen, a legal entity that falls under the auspices of human rights. As such the individual is someone who can (or has previously) expressed their choices, wishes as to their health, care, well-being, best interests.
• Being an INDIVIDUAL within the family of humankind - 1 of some 6.x or > 7 billion - this person is unique and deserving of highest quality care, dignity and respect that should be accorded to all people.
• Health and social care whilst organisationally distinct (POLITICAL - POLICY) are to the INDIVIDUAL and carers (GROUP) concurrent, transparent and ideally integrated activities.
• Physical care (SCIENCES) can be, and is, defined in mechanistic terms; for example, time (objective), events, place, outcomes, observations / data (discrete, quantitative).
  
• Physical care is hence primarily objective.
• Emotional INTERPERSONAL care can be, and is defined in humanistic terms; for example, time (subjective), communication, responses to events (behaviour), feelings, beliefs, relationships (SOCIAL), expectations, fears, observations / data (subjective, qualitative).
• Physical care, emotional care is often mediated through the SOCIAL domain and the group - the family unit.
• Since this model indicates an initial structure and content the model is of potential use as a reflective resource for novice through to expert.
• The model is generic and as such not limited to health and social care.
• Such is the generic nature of the model it can support all learners in lifelong learning.
  
• The Spiritual is not there: it is ineffable. It is everywhere, everything, every'I' and everynow.
• Time is inherent in several forms within health and social care.
  
• The economics of health care is infused to all the domains, notably in the first instance to the SCIENCES and SOCIAL domains.
• The economic effects upon the individual in a humanistic sense, may be remote, but is inverse in terms of its impact.
• The model reinforces dualism: mind - body (but cognitively innoculates also).
  
• In highlighting boundaries, dichotomy, limits the model can stress the need for integration.
• The model suggests an antipodean fracture in relationships*: the patient and clinician (across physical care and mental health) inhabit the Northern hemisphere; while the carer (public), manager and policy maker the Southern.
• Health and social care is grounded in human communication (and that which is mediated).
• 'Sense making' must be a key issue in health and social care.
• Given the scope of the model, technology must be making a major impact across all fields of health and social care.
• The model can simultaneously represent the SOCIO- and the -TECHNICAL.
• A great many (potentially - all) values and standards are inherent in the model.
• This model can be represented using many media.
• This model is open to the Management Consultant's delicacy alphabet soup, i.e. using letters to represent approaches / methods, e.g. 4P's, 4C's.
• Health and social care can also be described holistically.
  

*Clearly, given the relationships and issues that arise this bears further examination and discussion.

This list is subject to revision - addition.

Image source:
http://en.wikipedia.org/wiki/File:Antipodes_LAEA.png

Paper: The health career model in forensic nursing

The other week a paper was submitted to a journal on the application of Hodges' model in forensic nursing.

I am really pleased to have worked on this as a co-author and to find the health career model proving its relevance and value in such a challenging care environment.

Basically we divided the work and the paper as follows:

• Introduction to Hodges' model (new material);
• Explanation of why the model is relevant in forensic mental health services;
• Applying key principles of theory and practice of forensic care to each care domain;
• Discussion, recommendations and future directions.

Of course, this is just the 'submission' stage, so I will share news and details here in the near future - for now it's fingers x'd! If you believe the above 'content formula' might be useful to you as a publication template please do get in touch: h2cmng AT yahoo.co.uk

Topicscape Care Domain links in 3D - for the PC

Following the post on Sunday, January 24, 2010 I have tried Topicscape and the 3D rendition of my links pages which is for the PC only. Unfortunately, for me the experience is very slow as my 7 year, 2 month old Pentium 4 2.6Ghz with its equally aged graphics card is really not up to the task. If you have a recent PC with a suitably endowed graphics card*, perhaps you will see what I sadly - for the time being - am missing.


Thanks again to Roy Grubb for recognising the organisation and effort behind the four links pages I have compiled from 1998 to date. There's a great irony in my viewing the links as a 'monster', then here they are rendered by GPU's that more commonly play host to a variety of game monsters. Recently people# have let me know of their surprise and pleasure to see that there is still a role for a human hand (and reflective mind) to weave something beyond raw Google. Of course the developments in the semantic web and RDF ... can take this even further.

Additional links:

Hodges' model links in 3D with Topicscape

*I plan to correct this in the near future with a new PC sporting a CUDA capable graphics card - also for SETI @ Home et al.

#Dear Peter

Many thanks for this, I look forward to reading the material and learning more on what seems to be an interesting model.
I’ve added a link on our site to yours – the wealth of links available on your site is phenomenal!

Many thanks and kind regards

Charley
---------
Charley Baker
Madness & Literature Network
Research Associate
Fellow of the Institute of Mental Health
University of Nottingham
School of Nursing, Midwifery and Physiotherapy
Education Centre,
London Road Community Hospital,
Derby, DE1 2QY

RCN UK 2010 General Election 6 priorities - framed in Hodges' model

Please sign up: NURSING COUNTS

The RCN's 6 priorities hit the POLITICAL sweet-spot. In the table below I have related each of the priorities to a care domain of Hodges' model with a rationale that follows:

Give nurses time to train	Protect the Nation's health
Improve care for those with long term conditions	Standing up for staff who speak out Safer staffing levels Sustain health care investment

Timeout from the clinical arena for training is always a political issue. It is also at the behest of the individual. This includes individual practitioners and their managers.

The public's health (and mental health) is of course grounded in the group, but is initially framed by evidence, knowledge and preventive medicine.

Long term conditions may impact the quality of life of the individual concerned, but the effect on carers and the social ripples are also profound.

The Demand - Supply equation in health care may be reduced to raw, mechanical numbers, but they quickly become the political football of investment statistics.

So many false economies in stretching the more expensive resources when it comes to staff AND patient (carer) safety. Skill mix and staffing levels are vital for job satisfaction, service development, quality and safe outcomes.

Motivation and intent may be concepts exercised by individuals, but the political environment must support nurses who speak out for high standards of care, safety, the public good.

Hodges' model links in 3D with Topicscape

Roy Grubb (Hong Kong) got in touch recently regards his appreciation of the links resource I have compiled, organise and maintain using Hodges' model. Roy's intention to create a Topicscape in 3-D has now borne fruit. Unfortunately, on my Macbook Firefox fell over trying the link below. I then learned Topicscape runs on Windows PCs only. I look f/w to trying on my (aged) PC, but despite that limitation - this is a great development. Many thanks Roy!!

Here is Roy's post from his site (the larger image below with link is from his initial post):

I wrote about this a couple of weeks ago. Now that I have permission from Peter Jones to use the lists on his pages of links organized according to Hodges’ Health Career Model, I can announce that it is on-line and live in the form of a read-only Topicscape. You can search (just type) and visit the pages (links are in the details panel – just click). Links to the four main pages of links in the Hodges’ Health Career Model site are in the four main topic cones: Intrapersonal, Political, Science, Sociology.

Give it time to load the Topicscape software first time. Subsequent visits will be much quicker.

For you to fly around and explore this you will need a PC with 3D graphics hardware with an up-to-date graphics driver (requirements here).


There’s a wiki page with some helpful pictures that explain the few things you need to know to get you flying and zooming with the best of them. If you need any help, email me at r dot g at topicscape dot com.

Roy

Additional links:

The medical profession and mind maps – the quiet ones

Topicscape - Roy's initial post 'Hodges’ Health Career Model'

Science domain: H2CM (Visualization I & II, VR, Diagrams)