Care Logistics: have model will travel ...

From: NHS Logistics - supplies, v4m, corporate, orders, consultancy, catalogue, process, delivery, stock, just in time, service, quality, priority, efficiency, customers, finance, contracts ...
	To: Care Logistics - access, choice, attitude, empathy, communication, values, outcomes, human rights, dignity and respect, quality care, professionalism, purpose, roles, holistic competency, standards, personal, measures, equity ...

compose, direct, conduct and 'dilute to taste' outcomes

In Drupal musings 12 I mentioned that the classification of nursing practice is not necessarily at the forefront of nursing's mind set against the turbulence and rush of clinical areas.* This is especially so at the moment as nurses on wards, clinics and community try to identify savings.

I am interested in classification in part as this is the raison d'être for the health career model; on a mental (cognitive) level, in practice and potentially in virtual representations of health care activities. For learners it is an extra to hold the bicycle saddle for those first turns of the pedals. Additionally, for those who have completed many rides and races (lifelong learners) they can reflect on how they got there, and plan for the next round.

As a conceptual framework then h2cm is, like classification, in the background. The model can help to compose, direct and conduct (c-d-c) nursing (health and social) care. Classification matters to ALL nurses because we need to know not only the c-d-c of nursing but the outcomes too.

If all the above is in the background, then together with classification the health career model can help differentiate nursing as a discipline and make nursing visible. We can only take heed of the adage "divide and conquer" by being able to differentiate nursing from other disciplinary contributions. Then perhaps we can truly identify and so define the facets of integrated, interprofessional and multidisciplinary care that must also be person-centred. As nurses and the team respond to the individual's trauma (assault, illness, chronic disease ...), they can also assure their combined values, which must be defined and articulated if there is to be a unified philosophy.

If the respective professions have not noticed (I am sure they have) 'professionalism' is itself under assault in terms of unique knowledge and skills, respect, power and status. To a degree this a good thing. It is also called 'progress': countering restrictive practices, improving service access and challenging institutionalised and state paternalism. Professionalism is accorded for reasons of accountability, education, responsibility, integrity and advocacy. Amid the public (mental) health disaster that we face - the professions - are needed more than ever and if the assault is taken too far ... ?

* Should you know of examples where classification IS at the forefront of nursing practice please let me know - h2cmng @ yahoo.co.uk.

College of Social Work

At the moment there is an ongoing consultation relating to the creation of a College of Social Work. Here is an explanation from the website - http://www.collegeofsocialwork.org.uk/

Welcome to the home of the campaign for an independent, professionally led national college of social work across the UK. This website is dedicated to supporting the development of a fully independent national College of Social Work which will seek to improve and support social work by providing leadership by and for the profession.

The College of Social Work will lead the development of the profession and represent it in discussions with organisations that regulate, train, work with, and are affected by social work.

For further information on BASW or the campaign for the national college of social work, please visit http://www.basw.co.uk for the latest news, information and updates.

Take part in discussions online in BASW's member-only forum at MyBASW Exchange

If you would like to get in touch with your local BASW office, please find our contact details at http://www.basw.co.uk/contact

For several decades social workers have been my colleagues on the ground floor, doing the 9-5 turn and more. I once started a talk to a local constabulary on service development and thought the reception was a bit odd: the introduction met with a frosty tone in high summer. Things settled when I revealed I was a nurse, not a social worker. The audience highlighted the need - this was well over a decade ago - for more effective out-of-hours access to social work and mental health service colleagues. Things have improved markedly and with ongoing re-organisation pressures on the NHS and social services, the need for radical change has now shifted to social work itself.

I do hope the new College of Social Work will consider the health career model as a potential foundational and lifelong learning resource. The qualities and relevance of the model to the social work profession are manifold, and include the model's being:

• person-centred -
• the model is also socially oriented (25% of the model concerns the 'social' agenda);
• recognizes the oppositional experience of person - state / law;
• can support reflective models of practice for new learners and established staff;
  
• the vulnerable can be represented there - infants, adults, older adults ...;
• multidisciplinary in scope, or phrased another way - discipline neutral;
• multi-contextual in scope, individual (self), group (family, community), service (resources, policy), budgets (financial), recovery, strengths, information-education, quality and outcomes (reporting);
• a currency to support interprofessional education and training, and -
  
• prior to the above provides a tool for curriculum development.
  

Best wishes to our social work colleagues as they set out on their own journey, which can also provide a vehicle for sharing.

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.

Health care and handedness

The word legerdomain featured on Wordsmith's Word.A.Day as listed below:

PRONUNCIATION:
(lej-uhr-duh-MAYN)

MEANING:
noun:
1. Sleight of hand.
2. A display of skill.

ETYMOLOGY:
From French leger de main (light of hand), from leger (light) + de (of) + main (hand). Ultimately the from Indo-European root man- (hand) that's also the source of manage, maintain, maneuver, manufacture, manuscript, and command.

It is a shame and a matter debated at large that specialists - whether medical or of other disciplines - are not held in the high esteem that they once were. And yet when you come across a leader and specialist in their field the way they deploy their knowledge, insight and skills remains something to greatly admire and respect. I mean knowledge and experience that transcends sole reliance on interpersonal skills and blinding people with jargon and 'science'. Such are the outcomes of what the specialist brings to the (operating?) table, that it may even seem like a sleight of hand. Not in the sense that it is a trick, but there is an effortless transparency to not only what they achieve, but how they make people - their patients, clients feel. Not just feel, but how these people react and may find themselves.

If there is a sleight of hand it is in how while a specialist, they can and do cross boundaries. They see and can count the important numbers (evidence) in their discipline, but they know (from some no doubt hard-won lessons) that frequently some of the numbers in the very sequence they need lie outside their comfort zone.

RIGHT-handed (mechanistic)

or

(humanistic) LEFT-handed

- they know there is a

middle

and they cross it, without anyone noticing.

Basic Nursing Care @ the X-roads?

Basic nursing care:

It sounds straight forward enough doesn't it?

And yet according to news today here in the UK (The Independent) some nurses it seems fail to deliver safe, effective and efficient care of the required standard. This sorry news was reported by The Patients Association. The cases cited are upsetting and represent the care and behaviour of a minority of nurses, although there was a debate as to the 'true' numbers the report findings may represent.

The worrying point here though is this highlights not just a lack of basic nursing skills and knowledge, but a blatant disregard for the needs of vulnerable individuals and a sense of humanity. Even with NVQ's in the UK and equivalent programmes elsewhere when it comes to high standards of care we can take nothing for granted.

A commentator on the radio asked if the nursing profession is at a crossroads?

It is.

This crossroads is also a target that nursing must hit -
not most of the time -
but every time and for every person.

In truth of course, all professionals should constantly find themselves at the crossroads.

So, where next for nursing and who has the map?

Original image source:
http://www.thesignlady.net/signs/images/warningsigns/W2-118X18CrossRoad.jpg

(Confidential) Letter to self - and you, and you, and you... ?

Hi PJ,

I'm wondering if you can help with something that's been troubling me a bit...?

You know that as a nurse (and future patient!) confidentiality (which increasingly relies on the security of ICT systems) is of course vital to your profession and professionalism both in theory and practice. Quite rightly take this for granted and you could be in serious trouble, with your job in jeopardy.

I’ve been wondering about the way that Jo-public views their personal health information and clinical record and how these views have evolved over the past decade and how they will change in the next 5, 10 .... years? A change that will have major implications for definitions and the meanings of record, access, sharing, personalised, and professional. This is also one of those slippery slopes; since it will be very difficult to get that emerging genie back in the bottle. The clinical record even with new consent models will increasingly make it a currency for exchange within a *wider* community given the rise of electronic and personal health records, Health 2.0, 3.0…. By 'community' I mean one not just restricted to health and social care organizations, but one that could be much more extensive.

There are a lot of tools out there in the public domain that enable the creation of new portals, services to which other agencies can add value. This is not a problem: 'value-added services' is one definition of progress.

The problem is the pace of change and the extent.

Health has always been commodified. Recently on the news I heard that a kidney is probably worth 1.5 million dollars.

Perhaps for the ‘professions’ given the sanctity of clinical records this is the ultimate trip?

Any thoughts or directions to references…?

Many thanks and best regards,

'Your other half'
P.S. People had better be careful when they mix personalised and professional - that's quite a potent concoction. I wonder if you can sell it?

<->

Additional links / reading:

Nursing & Midwifery Council - Standards

Viewpoint Paper

A Research Agenda for Personal Health Records (PHRs)
David C. Kaelber, Ashish K. Jha, Douglas Johnston, Blackford Middleton and David W. Bates
Journal of the American Medical Informatics Association, Volume 15, Issue 6, November-December 2008, Pages 729-736.
Abstract:

Patients, policymakers, providers, payers, employers, and others have increasing interest in using personal health records (PHRs) to improve healthcare costs, quality, and efficiency. While organizations now invest millions of dollars in PHRs, the best PHR architectures, value propositions, and descriptions are not universally agreed upon. Despite widespread interest and activity, little PHR research has been done to date, and targeted research investment in PHRs appears inadequate. The authors reviewed the existing PHR specific literature (100 articles) and divided the articles into seven categories, of which four in particular— evaluation of PHR functions, adoption and attitudes of healthcare providers and patients towards PHRs, PHR related privacy and security, and PHR architecture—present important research opportunities. We also briefly discuss other research related to PHRs, PHR research funding sources, and PHR business models. We believe that additional PHR research can increase the likelihood that future PHR system deployments will beneficially impact healthcare costs, quality, and efficiency.

From the above:

Markle Foundation http://www.markle.org

Robert Wood Johnson Foundation http://www.rwjf.org

Considering something ‘ELSE’: Ethical, legal and socio-economic factors in medical imaging and medical informatics
Penny Duquenoy, Carlisle George, Anthony Solomonides
Computer Methods and Programs in Biomedicine, Volume 92, Issue 3, December 2008, Pages 227-237.

Abstract:
The focus on the use of existing and new technologies to facilitate advances in medical imaging and medical informatics (MIMI) is often directed to the technical capabilities and possibilities that these technologies bring. The technologies, though, in acting as a mediating agent alter the dynamics and context of information delivery in subtle ways. While these changes bring benefits in more efficient information transfer and offer the potential of better healthcare, they also disrupt traditional processes and practices which have been formulated for a different setting. The governance processes that underpin core ethical principles, such as patient confidentiality and informed consent, may no longer be appropriate in a new technological context. Therefore, in addition to discussing new methodologies, techniques and applications, there is need for a discussion of ethical, legal and socio-economic (ELSE) issues surrounding the use and application of technologies in MIMI. Consideration of these issues is especially important for the area of medical informatics which after all exists to support patients, healthcare practitioners and inform science. This paper brings to light some important ethical, legal and socio-economic issues related to MIMI with the aim of furthering an interdisciplinary approach to the increasing use of Information and Communication Technologies (ICT) in healthcare.

Situation-Based Access Control: Privacy management via modeling of patient data access scenarios
Mor Peleg, Dizza Beimel, Dov Dori, Yaron Denekamp
Journal of Biomedical Informatics, Volume 41, Issue 6, December 2008, Pages 1028-1040.

Abstract:
Access control is a central problem in privacy management. A common practice in controlling access to sensitive data, such as electronic health records (EHRs), is Role-Based Access Control (RBAC). RBAC is limited as it does not account for the circumstances under which access to sensitive data is requested. Following a qualitative study that elicited access scenarios, we used Object-Process Methodology to structure the scenarios and conceive a Situation-Based Access Control (SitBAC) model. SitBAC is a conceptual model, which defines scenarios where patient’s data access is permitted or denied. The main concept underlying this model is the Situation Schema, which is a pattern consisting of the entities Data-Requestor, Patient, EHR, Access Task, Legal-Authorization, and Response, along with their properties and relations. The various data access scenarios are expressed via Situation Instances. While we focus on the medical domain, the model is generic and can be adapted to other domains.

Patient Information Advisory Group - PIAG: http://www.advisorybodies.doh.gov.uk/piag/

Picker Inst. http://www.pickereurope.org/

Weber: Universities, disciplinarity - academic publishing

As I read through the latest book I have received for review, I came across this interesting quote from Samuel Weber:

The university, itself divided into more or less isolated, self-contained departments, was that embodiment of that kind of limited universality that characterised the cognitive model of professionalism. It instituted areas of training and research which, once established, could increasingly ignore the founding limits and limitations of individual disciplines. Indeed, the very notion of academic "seriousness" came increasingly to exclude reflection upon the relation of one "field" to another, and concomitantly, reflection upon the historical process by which individual disciplines established their boundaries. Or the historical dimension was regarded as extrinsic to the actual practice of research and scholarship: history itself became one discipline among others. (1987, 32)

Weber, Samuel. 1987. Institution and Interpretation. Minneapolis: University of Minnesota Press. Revised and reprinted as Samuel Weber, 2001. Institution and Interpretation (Expanded Edition). Stanford, Calif.: Stanford University Press.
Cited in Hall, Gary 2008. Digitize This Book!: The Politics of New Media, or Why We Need Open Access Now. University of Minnesota Press. Chapter 2, Judgement and Responsibility in the Wikipedia Era, p. 74.
(My review of Hall's book to follow).

To blog or not to blog - that is the question?

Much has been written - blogged about even - as to whether clinicians should blog or not. In a recent article and the Health Service Journal's new blogs this question has been raised.

As the cogs turn, I'm a very small one; but even as a nurse and blogger I am acutely aware that being on the web is the equivalent of the old town square. That square is increasingly global (at the month's end).

The stocks sit there plainly visible, prompting pause for thought ...

Blogging on the HSJ Nadeem Moghal made the point about the risks of being a clinician, a blogger AND being tired and frustrated to boot. Mr Moghal also references a source which advises that clinicians should not blog.

There are reasons not to blog as a health service employee. Like everyone I get tired and frustrated too. You have to remember your contractual and professional obligations, plus your relationship (actual and potential) with the people in your care.

That said, the government, NHS, Connecting for Health and others need to consider what they want in terms of the skills and experience of the professionals it employs. Using nurses as an example - is it enough that nurses are 'IT users' and 'web-savvy'? Or should nurses, academics and other professionals be capable of critiquing the hardware on their desks, ward trolleys, the software they use (and help develop) and the associated issues that arise? In the sense that we are professionally accountable, then a given level of insight and understanding of new media and technology forms is vital. There are a lot of issues: take for example Rod Ward's recent post on access to records.

Perhaps some established journalists are worried about the changes in the(ir) business? I am part of that media demographic that Sir Michael Grade must worry about over at ITV. Being on the web means you watch less TV, amongst other things...

To agree that clinician's should not blog and close-up shop is to consider and respond to the situation in purely political terms.

Despite the dangers of being online - in person - I believe there is a case to demonstrate that this new media can provide a marvellous and effective outlet for new (and old) perspectives on what it is to care. Whether wearing a white coat, driving around the community or writing your latest post if you have a message then surely it can be delivered in a professional manner?

For me here on W2tQ
I've some help in not just having a message
but also having a mission.

To focus on the politics alone, is to ignore the role we also have in teaching and mentoring others. This should include not only students, but members of the public too: see healthspace and personal health records. ... IT literacy, political literacy, health literacy, media literacy - there's no end to the 21st century skill set ....

So if you blog,
tread carefully,
listen and pay attention to the constantly breaking glass.
Politics (and your job) does count!

And yet blogging can be about more than just politics:
it can be about creativity and exploration.

h2cmuk at yahoo.co.uk

"Let us put our minds together
and see what kind of life we can make for our children."
--Chief Sitting Bull (1823-1890)

Image source: Tony Woof.com