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...?

Musings... axes in hand and mind

...

Axes in hand and mind
[Accounting for the I-G (individual-group) axis and the need for the H-M axis]

Clearly there is a need for a basic scaffold. One that reflects the real world and the real time to which we are all exposed and are a part; and one that can also represent the model(s) we wish to create - the products of our health care, nursing activities. The scaffold we build must be one on which we can hang concepts and for simplicities sake human (care) concerns. Specifically a conceptual scaffold and a human scaffold. The latter can be represented simply as a continuum from INDIVIDUAL to GROUP, hereafter referred to as I-G.

The other, the conceptual scaffold, calls for what might be termed conceptual inflation. If we imagine the I-G as the vertical challenge (remember the health & safety issue!) and draw with the 'individual' at the top, then there is much we can model based on this basic dichotomy. This is too simple however. We cannot capture the part of the rich tapestry that is life - well-being, health - and death. For this another axis is needed.

(Which begs me to ask myself:

is there a law that suggests that one axis however oriented invites another?)

With this further partition and heralding of a further dichotomy what is lost? What is gained, if anything? In scribing this first line we explicitly separate the 'one' - the self from the other. The addition of another axis is where and how we define a center. With this center and from it we can find the energy to fuel our conceptual inflation. We literally draw out the foundation by considering what these persons do? ...

Conceptual inflation: Four-fold nursing agnostics
...
PJ Dec 2010

Musings... building models, health & safety, group and individual

....

Basic foundations and minimal defaults
[Accounting for the I-G (individual-group) axis]

Since nurses and technologists are concerned with communication then the foundation from which they begin to (build and model their) work is of fundamental importance. The foundation needs to be generic in the first instance. Generic in the sense of the commonality that language instills, enables and facilitates within and between communities. Not only that, but if we take the property of 'generic' to its extreme then the foundation must be stripped down to the barest of defaults: there are no 'types'.

To use the safety analogy we need to risk assess the extent of our model building activities.

We can do this by asking: is this a one, or at most two dimensional venture; such that we can rest secure on terra firma? Or are we above 'ground' floor and immediately required to address health and safety legislation?

Since medicine and nursing are concerned with - must be evidence based - there is an immediate  vertical challenge in the hierarchies inherent in the sciences and the structure of knowledge.

Science is not the only influence here. The foundation of what we are modelling and building must reflect the ultimate subjects (the person - patients, carers, communities, whole populations) of our activities. So, the individual (whose very safety is our concern!) must be factored in and with this concept the notion of human rights. While a dialogue of no trivial nature in itself, suffice here to suggest that individual and applied human rights emerges out of and is dependent upon the collective (group). This in turn is a measure of the level of social coherence, coherence through a level of social and political organisation that allows leaders to effect positive change and betterment. The person, the individual is built not upon the shoulders of giants, but ordinary people - our ancestors and peers. ...

Axes in hand and mind
...
PJ Dec 2010

CfP IEEE IC Special Issue: Web Technology and Architecture for Personal Health Records (July/August 2011)

IEEE Internet Computing: special issue planned for 2011

Guest Editors:
Chimezie Thomas-Ogbuji [cut at case.edu], Karthik Gomadam [karthik at knoesis.org], and Charles Petrie [petrie at stanford.edu]

Final submissions due 1 November 2010
Please email the guest editors a brief description of the article you plan to submit by 15 October 2010.

The healthcare industry is well positioned to take advantage of contemporary Web-based architecture to address the technological challenges of personal health record (PHR) systems, many of which require simultaneous advances in engineering, informatics, and network-based applications. Of particular interest are the PHR systems that capture healthcare data entered by individuals.

This special issue seeks original articles describing development, relevant trends, and challenges in incorporating contemporary Web-based technology for the primary functions of PHR systems. The main functional categories of interest are information collection, sharing, exchange, and management.

Appropriate topics of interest include:

• Web-based, structured data collection in PHR systems;
• implementations of access-control policies and healthcare data sharing;
• distributed, identity-based authentication methods;
• digital signature and encryption techniques;
• Web portal architecture’s general components and capabilities as the basis for a PHR system;
• architectural paradigms regarding connectivity to other healthcare information producers and consumers;
• data models for PHR systems;
• distributed data subscription and publishing protocols;
• successful Web-based applications for chronic disease and medication management;
• health applications for PHR systems on mobile devices;
• privacy and security issues;
• HIPAA and its implications for adopting cloud computing for PHR applications; and
• semantics for PHR interoperability and applications

http://www.computer.org/internet/cfp.htm

All submissions must be original manuscripts of fewer than 5,000 words, focused on Internet technologies and implementations. All manuscripts are subject to peer review on both technical merit and relevance to IC’s international readership — primarily system and software design engineers. We do not accept white papers, and we discourage strictly theoretical or mathematical papers.

To submit a manuscript, please log on to Manuscript Central (https://mc.manuscriptcentral.com/cs-ieee) to create or access an account, which you can use to log on to IC‘s Author Center and upload your submission.

Nursing attitudes [towards patients ( and self { and ? } ) ]

In the past half-year there have been two discussions, that concern the nurse's attitude towards patients.

One was held on the nursing philosophy list in February:

https://www.jiscmail.ac.uk/cgi-bin/webadmin?A0=NURSE-PHILOSOPHY

"The patient is always right"

The other in May was on the mental health in higher education list:

https://www.jiscmail.ac.uk/cgi-bin/webadmin?A0=MHHE

"Insufferable' or 'Suffering' - a response"

Both provoked a similar response and debate. I have just reprised my post in February on the MHHE list and have copied it - with some revision - below:

<->

Patients are always a challenge in that they come in lots of 'varieties'.

This is why we recognise the need for individualised, person-centred care. One variety is trauma laden to which the full-complement of the multidisciplinary team must respond. These patients and *their* crises bring out the best in us in terms of the skills and knowledge, team work they force us to exercise.

Among the plethora of other varieties there are those who are viewed as 'problems'. Like the Pepsi ad of decades ago they are variously and pejoratively described as multiple attending, attention seeking, patience sapping, heart-sinking, time wasting, symptom preoccupied .... patients.

If I receive referral information, or heads up information on diagnosis that suggests the above what do I do?

• Brace myself for impact?
• Become task focused?
  
• Share collective anecdotes in the staff room as a way to cope, unstress, inject some humour?

OR -

• Avoid labelling them or use these labels in a re-constructive way?
• Refuse to make gross assumptions
• Look at the individual non-judgmentally, holistically, educationally, behaviourally
  
• Believe I can make a difference (change is always possible [inevitable] )
  
• Side-step being tripped by foibles, behaviours and blatant displays of -ve obstructive ... attitudes that offend 'me'
  
• Enter their space and do my utmost to find room for manoeuvre?
• As a nurse do go and seek out strengths and opportunities in the same way that Capt Kirk et al. go and seek New Life, New Civilizations..?

You may have an impossible lock to pick. In its most severe form this is (pejoratively) known as 'personality disorder', but the nursing challenge is there in all its personal and professional glory.

So. Listen.
Attend to this personal
/ under-the-skin \
slant.
Listen and Learn.

Be aware of the pit that continues to trap many people. The life chances - the health career - that they may have missed, took for granted, spurned and much more you (we) will never know about.

Do your job: nurse.

Philosophy of information empowers philosophy of care

The moral and ethical dimensions of nursing quickly become apparent to individual practitioners and professional associations. Philosophy in nursing boasts specific courses, journals and groups, for example:

International Philosophy of Nursing Society (IPONS)

Nursing Philosophy (journal)

International Centre for Nursing Ethics

Here on W2tQ, in papers and on the website I have stressed the importance of the health career model as a framework that can utilise information as a fundamental and potentially unifying concept.

Expanding on the post last week about the philosophers' magazine [tpm50] let's look at Floridi's piece on the philosophy of information (PI). The 50 ideas featured are each only granted two pages, but this has a definite philosophical equivalent twitter-styled appeal. On page 42 (- 43) Floridi notes that:

... PI possesses one of the most powerful conceptual vocabularies ever devised in philosophy. This is because one can rely on informational concepts whenever a complete understanding of some series of events is unavailable or unnecessary for providing an explanation. Virtually any issue can be rephrased informationally. Such semantic power is a great advantage of PI, understood as a methodology. ...

It shows that we a dealing with an influential paradigm. But it may also be a disadvantage, because a metaphorically pan informational approach can lead to a dangerous equivocation, namely, thinking that since any x can be described in (more or less metaphorically) informational terms, then the nature of any x is genuinely informational. (Luciano Floridi, 2010).

Admittedly Floridi's context is the position and status of PI as an emerging discipline within philosophy. As he notes the vocabulary while powerful lies in the discipline of philosophy.

Given my preoccupation with information, Floridi's observation above is a timely warning for me and the many nurses who in the past saw a concomitant risk that in adopting the nursing process, patients (and carers) would be processed. Ironically, this processing concerned information. The workflow - form and layout of the documentation - was prescribed. This is an old tale, with the nursing process being subsumed within the routine work of nursing. Perhaps though this also demonstrates a need for a new debate?

My interest in information is as a trope to explain the significance of the care (knowledge) domains that underpin Hodges' model. Crucially, though these can stand on their own as nursing philosophy issues. Joining the efforts of the nursing philosophers above, this can bring information and philosophy out of the academic realm to include a more practical and grounded variety of topics:

FROM: personal identity,
definitions and ownership of computer based records,
utility versus security of information (summary care record ...),
definitions of information (data, knowledge) - through
TO: patient information and patient informatics, ...
where is collective informatics^# heading?

Taking Floridi's lead - which of the above .... are core nursing (health) information concepts (and not just freeloading info-masqueraders along for the ride)? Well, that is a question for a new community of scholars to decide?

Philosophy resources: Interpersonal care domain

^#Collective informatics = all the claimed informatics disciplines combined?

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