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...?

Dementia care: communication in nursing homes

In nursing home liaison the importance of communication quickly asserts itself (as it does throughout health and social care). As an organisation effective communication is evident (or should be) at all levels:

• Corporate: across the 'group'
• Management: within the home
• Clinical: continuity of care between shifts, days - nights
• Care staff and residents - especially those with challenging behaviour
• The care home (staff), relatives and community

This week and as also recognised for colleagues in the future, my role will focus on education. In particular reviewing the background, theory and practice of communication with people who are more severely disabled by this condition. I've sixteen slides as a guide, a lesson plan but I will be using a flipchart (arriving early to scribble away) with the intent to engage the audience. Given my pre-occupation with information I want to mix and match as follows:

1. Use information as a central concept, not technically but personally as per self-awareness, knowledge and orientation, person-centred care.
2. Have people contemplate communication in a practical sense.
3. Finally, obviously ensure that what is discussed and shared is directly related to their work, the care needs and challenges of the residents (and families?).

On the information front I'm sure I can employ the conventional and simplified communication model:

SENDER - channel - RECEIVER

This may appear mechanistic but it's an effective way to highlight the real difference that Health Care Support Workers - and indeed family and friends can make to resident's lives. Referring to this model I can demonstrate the very upsetting inequalities that are often found here. The audience can contrast themselves as SENDER and RECEIVER with each other and in care scenarios.

We will identify and acknowledge the deficits that people living with dementia must contend with and endure. This is to review previous learning and ensure staff fully appreciate the care situation. More positively the session will stress the role of staff as builders and agents of personalised care with a great contribution to make.

1. They can consider (critically) the care environment - yes the 'home' - as the source of potential noise. 
2. When there is an imbalance in the capabilities, comprehension and meaning between SENDER and RECEIVER skilled, insightful, and patient staff can compensate, addressing the person's unique needs.

If there are matters that cannot be resolved then these 'risks to person-centred care' should be carried forward to management: a prescription that must be repeated as necessary. With the purported high rate of staff turnover in homes (is that a myth - what are the figures really?) they should be able to leverage these FFIs - frequent first impressions - from new staff, before they are also part of the furniture.

Allied with this is a request for support in person-centred care. For me these two go together and it's good that this 2nd session follows tomorrow. This is an opportunity to introduce the Health Care Domains Model and build upon the points raised and factor in the questions and issues raised by the staff.

Critically across all these layers of comms is: Leadership. A key part of that of course is recognising training needs and pursuing change.

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

Before you measure ....

Fitness-to-work tests to be reformed after criticism

- you check your tools:

You calibrate, validate and balance ...

strengths - weaknesses

functional - diagnostic

humanistic - mechanistic
individual - group
purpose - policy
practice - process

physical - emotional

person centred - policy centered
sad (?) - (you will be -) happy

Additional links:
How to assess happiness? A tale of three measures
WWF: Manifesto - The Politics of Happiness
Frank Furedi: Why the ‘politics of happiness’ makes me mad

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 ...

Drupal(con) musings 14: design, UI, UX, thinking and care

In his funny and very engaging session 'Designing UI with Seven' at Drupalcon CPH Mark Boulton discussed four user experience (UX) principles and introduced us to ten user interface (UI) guidelines.

Mark highlighted the need for a mental model and the challenge within publishing of there being someone who has the big picture. Who knows exactly what is going on? The health career model provides a model and can provide a canvas to support the big picture.

What really caught my attention though was as soon as Mark asserted -
"Don't make people think." -

I immediately thought -
'Make people care instead'.

Well, I'm not sure if an interface can do what public (mental) health policy, government public funded education programmes and the concerted efforts of the health professions has largely failed to achieve. The users of e-health information systems do need the design of the system to be transparent to them. IT mustn't get in the way. Mark's point of course is the the user's should be free to focus on the problem the system is to help solve. In health this includes:

• recording of a health (and social) care record;
• secure information / file management and access;
• information governance, reporting and archiving;
  
• timely, ready access for those who need to know;
• ability to manipulate the record to obtain knowledge: from data > from information;
• to provide patient (carer as advocate) access and verification;
• remote access with rugged devices.
  
• ...
  

This does not mean that people are oblivious to design: far from it (iThis - iThat!). My point is that as we follow Mark and other design expert's advice then users should be able to focus on care design and the care outputs arising.

So in health we need interfaces and user experiences that DO encourage reflection, thought: thinking.

P.S. In another session (or magazine!?) on creating mobile versions of sites the advice included getting rid of the crap - the clutter, the >1000px width adornments. Rhetoric aside - my design thought would be not to include anything that could be described in this way whatever the media type (maybe I should lighten up!) ;-)

To follow: update on my Drupal efforts.

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, social care and informational emaciation

We hear a lot about information and how important it is, being in what is described as the information age, the information economy. ...

Nurses, patients and carers (plus managers) would instantly recognise that if a care plan and subsequent care delivery was based on the following assessment:

oriented, not depressed	hypertension, falls, dizziness, headaches, pyrexia
carer due hip operation	admitted 1st May 2010 1200hrs to clinical decisions unit

- we would be acutely concerned.

Clinically this is a case of informational emaciation. The information above is rather thin on the ground, this in turn affects the knowledge that can be gleaned in formulating, negotiating and agreeing actions. Even in the information sparse example above each of the care domains has some content; is that always the case?

Use of the word emaciated in this context is not intended to diminish the plight of people who are physically emaciated, poorly nourished.

This post is intended to highlight another aspect of poverty.

As the Global Healthcare Information Network (HIFA 2015) argues and campaigns - information is a means to emancipation - a way to overcome information emaciation.

Additional links:

Picker Institute Europe

Patient Information Forum

Patient Information Advisory Group

Romeo and Juliet – the care home version

Octogenarian versions of Shakespeare's lovers to feature in Bristol production

Directed By Tom Morris

Fresh from co-directing the West End hit, War Horse, and Tom Stoppard and Andre Previn's orchestral experiment Every Good Boy Deserves Favour at the National Theatre, Tom Morris' own theatrical exploration of Bristol Old Vic begins with a project that has been twelve years in the making: Juliet and Her Romeo, the story of a flourishing love affair in one generation, crushed by the financial and political concerns of another.

Developed since 1997 in collaboration with Minder producer Sean O'Connor, the production uses Shakespeare's text, but casts our lovers in their 80s, with their anxious children, not their parents, seeking to prevent an imprudent and costly match.

With Sian Phillips as Juliet and Michael Byrne as Romeo, this production invites a generation of actors of global stature to play great Shakespearean roles which they never thought they'd play again. Tim Barlow, Terry Taplin and Michael Medwin return to Bristol Old Vic as Tybalt, Benvolio and Paris. Dudley Sutton makes his debut on the Bristol Old Vic stage as Mercutio.

What family has not wrestled with the question of how we care for our parents as they become older and frailer? Who will love them? Who will support them? Who will pay for their care?

And with that care, what controls should we apply? If we have taken power of attorney, what about the freedom to fall in love, to give gifts, to marry unwisely?

As Ben Power's recent two-handed exploration of passionate love remembered in old age demonstrated, Shakespeare's text is a powerful love story for any generation.

Signed, Captioned and Audio Described Performances.

Signed performance: Sat 10 April 2.30pm

Captioned performance: Sat 17 April 2.30pm

Audio described performance: Sat 24 April 2.30pm

Additional link:

BBC Culture Show

Person-centred care and semantic inflation

Time laughs at us, with us and has the last laugh. If you are ever complacent and by virtue of your years you venture to think to yourself:

Well we've been working on this now for 20-30 years look at the progress we've made. ...

Time is always there to remind you:
Hey, just who are you trying to fool?
You are a lifelong learner!

The number of personnel and services that describe themselves as person-centred is an ongoing theme of so many CVs, policies, SLAs, commissioning and consultant's presentations and lectures. ...

Whether in a ward, service, or organisation's philosophy, person-centred is a term that is being diluted to the extent that semantic inflation devalues what is supposed to be the main currency? Or are we admitting that this is the cost of the political games that people play? Whatever your view, there are insights of progress won, but also reminders on how much remains to be done.

Health and social care being multicontextual demands the existence of multiple currencies. One additional currency begs that we compare A, B, C with the evidence base.

If this is the crucible of our person-centred times then what is burning?

• Nursing ethics?
• Nursing education?
  
• Idealistic aspiration? (Yes, we will get there!)
  
• New Age incense?
  
• Policy initiatives?
• Funding allocations?
• Nursing activism (Or, are there any balls in the house)?
  
• Service infrastructures?

Although the media temperature is rising here in the UK, as health, itself economically recumbent is moved to ICU being so politicised; the Francis Report provides evidence of a dire lack of person-centred care. Recalling my basic nurse training: what can be more person-centred than ensuring that a patient has the necessary fluids and diet?

For women who suffer a miscarriage - where should they be nursed as debated in today's Guardian newspaper? What is person-centred care in maternity and gynaecology services?

In-patient provision and transitions from child-youth-adult provide other opportunities and major challenges for health and social care to demonstrate their person-centredness.

There are so many ways to be person-centred, so many levels, some may even be contradictory(?).


I wonder how many of those people highlighted in the Francis Report also had a form of dementia - whether diagnosed or not? Personhood and the need to acknowledge and sustain the person are not new.

Even if a service is person-centred in terms of the environment, meal choices, therapeutic options, belongings, personal space, proximity to home and relatives ... the crux at the center is the attitude of staff, and their having the time and space:

"to be"

person-centred

Additional links:

Mumsnet

Atkins, L. (2010) NHS 'must lessen trauma of miscarriages' Parents web forum Mumsnet calls for new code of practice to help women who lose their babies, The Guardian, Tuesday 2 March.

Image source:
http://drugsreference.co.uk/books/books.php?cat2=Caregiving

'Problem patients?' 2 - Appease me do (not)

Many of the aspirations of nursing are just that - aspirational.

Appeasement and other similar 'power' associated concepts helps explain some of the appeal of Hodges' model - with its inclusion of a POLITICAL care domain. The needs of the ONE (interpersonal care domain) are diagonally opposed by the needs of the MANY (political care domain).

Just because I may approach someone (*evidently*) abusing medication / alcohol, over-eating, risk taking ... does not mean I am prepared to continue to nurse them and hence support them in that behaviour. Attempts to engage can be made and (must be) documented, as subsequent referrals and care will build on those care encounters. There is a marked difference between those individuals above who are often socially excluded, risk takers and people who are preoccupied with their health and mental health state. (Are such people stuck in the 'sick role?) Such patients may well seek new drugs and then instantly question the medication they are taking, never satisfied, they may query their care record and care while in hospital by virtue of their personality and anxieties.

I can reject negative behaviours and attitudes, but not the person. As a member of the health care team I can explain clear terms for future engagement should the patient wish. At the end of the day we constantly review: do they have mental capacity and to what extent does their behaviour present a risk to themselves, or others...? There is also a role for specific care management to be effected, to screen and prevent people reaching emergency services when this is repeated and unnecessary. The combination of some conditions such as long term respiratory problems and anxiety can create acute management problems, both for the individuals concerned, their family carers and care providers.

People do have choices to make, and so must take responsibility for how they exercise those choices.

Crucially this also needs to be explained to referrers - e.g. general practitioners / family physicians. For effective care management the inclusion of paramedic, crisis, social and intermediate care services in care management communication and coordination is also essential.

So, there is absolutely no need for a "current model of appeasement based care".

(This is a wind-up - surely? If not I am available for career advice.)

Yours truly and the patient's (even if it hurts),

Peter Jones

'Problem patients?' 1

Nurse Philosophy list

'Problem patients?' 1 - Wimps and space to care

I responded to a mail list discussion around 'problem patients' which began with the following main points:

• a relatively new nurse
• surprise that a significant minority of (my) patients are pathological wimps;
• even prior to seeing them they can often easily be spotted by examining their medical records;
• for example, I frequently notice that wimps have an obscene (and often downright odd) amount of special meal requests;
• current nursing philosophy encourages nurses to be endlessly supportive of wimps. i.e. to follow the often demonstrably wrong idea that "the patient is always right.";
• IMO nurses who claim they benefit such patients using the current model of appeasement based care are co-dependent personality types who enjoy feeling needed more than they enjoy actually helping people.

My first response is copied below with some additional points a further post will follow:

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 physical 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 -

multiattendin, attentionseekin, patiencesappin, bedblockin,
buzzabuzz-buzzin, heartsinkin, timewastin,
symptomfindin, carenumbin

.... patients!

If I receive referral information or heads up information on diagnosis of a 'tci' (to come in) that suggests the above is on the way, has arrived or worse "is on your caseload" - what do I do?

• Brace myself for impact?
• Go off sick (suffering loss of job satisfaction)?
  
• Become purely task or disease focussed, give up on effecting +ve change and improved outcome?
  
• Share collective anecdotes in the office - staff changing as a way to cope, de-stress, inject some humour?

OR do I -

• Avoid labelling them, or use these labels in a re-constructive way?
• Ask why are they 'who' they are?
• Gaze into their 'life history' and help them learn from it?
  
• Refuse to make gross assumptions, even based on previous experience with client - patient?
• Look at the individual wholistically - socially, educationally, behaviourally?
  
• Believe you can still make a difference (be the fly-half you can be and play ball)?
  
• Side step being tripped by foibles, behaviours and blatant displays of -ve obstructive ...... attitude that offend 'me'?
  
• Enter their space and do my utmost to find room for manoeuvre (this is the hardest test)?
• Speak to my manager(s) very tersely about protecting 'me' as a scarce resource and shout "OK where the hell is the gate keeper!"
  
• Or, as a nurse do you boldly go and seek out new strengths and new opportunities in the same way that Kirk, McCoy, Spock et al. (2264) go and seek New Life, New Civilizations...?

You may have an impossible lock to pick (in its most severe form this has become known as 'personality disorder'), but the nursing challenge is there in all its personal and professional glory. Address this personal - under-the-skin - slant - seek supervision. Be aware of the pit that some people fall into. The trap for some people with life chances they may have completely:

missed, never had, were stolen, denied,
took for granted, spurned,
totally - wasted.

Around the pit is the zone of judgement, but beware it is a singularity (no perspective) and very slippery.

• Otherwise go do your job: Nurse.

Nurse Philosophy list

Reference:

Kirk, McCoy, Spock et al. (2264) The Caring Imperative, To Boldly Go..., Four Quadrant Galactic Care Journal, Integrated Galactic Care Publishing Inc. itess-cube: 1701u-care4mesafelyandnicely

Dementia, Drugs, Nursing by Degr[EE]s and Care Transitions

Of all the policy issues that government faces the care of an ageing population is irresistible in demanding attention. This one will keep tapping MPs, policy makers and families ... on the shoulder. It will constantly cycle through the government's gamut of official papers. In the UK this past week people suffering with dementia and the prescribing of anti-psychotic medication and deaths arising from the same has been highlighted and not for the first time.

Whilst my spare time web attention is also given to nursing IT and socio-technical matters, as an NHS community mental health nurse these vulnerable individuals are the primary focus of my work and that of my colleagues. There are three strands to the current role - in brief:

• Nursing home liaison - dedicated to specific homes;
• assessment, intervention and subsequent review;
• working with social services integration project duty desk.

Drugs are of course a day-to-night constant for all nurses, with the addition of debate across all the knowledge domains of Hodges' model - that is interpersonal, sciences, sociology and political domains of knowledge. We have witnessed this in the scientific evidence of substance misuse and the government misuse of drugs advisory group 'difficulties' and now this issue which is professionally closer to home: right on the doorstep in fact.

'Home' is the operative word as many of the people concerned reside in residential care and nursing home facilities. Let's scratch the surface of what we already know:

• These people can be very confused, vulnerable, they may be agitated and not easily reassured and placated without repeated skilled intervention.
• Facilities are subject to inspection and care standards.
  
• Many do not have an advocate in the sense of a family member who visits at least weekly and will challenge and question care and prescribing.
  
• Older people may already be on several drugs (polypharmacology) due to other chronic health problems.
• There is still a disconnect (holistic gap!) between the interdependence between mental - physical health problems.
  
• These facilities are that individual's home - they continue to live and hence age there.
• Homes get attached to their residents; in the best homes they (and their relatives and friends) become part of a greatly extended family.
• For confused people there is a potential community (albeit a closed one) that people can participate in or choose to stay in their room. This space, the freedom of movement it affords - toing-and-froing - should itself be subject to history taking and ongoing assessment.
  
• The quality of this community depends on the core staff and additional skills seen as essential by the organisation and care standards, e.g. activities coordinators, residents committees that also engage family, friends.
• NVQs and mandatory training in the sector is making a positive difference.
• There remains a high level of staff turnover.
  
• Some homes are dual-registered catering for nursing care with another floor for dementia care (does a 1st or 2nd floor provide secure access to a garden in the summer?).
  
• Homes rely greatly on the specialist services of local community mental health service, also given the placement of people in homes 'out of area' this involvement may be more remote and subject to varying degrees of engagement and hence quality.
• Homes are businesses and the movement of clients incurs changes in income.
• The quality and standards of architecture and design for residential accommodation has seen great strides in the past decade.
  

The bottom line (no pun intended) is the need for macro-management in terms of multidisciplinary team input; that is, primary care, modern matron, mental health and micro-management in terms of personalised care with regular review of physical and mental well-being and medication.

As government's of all persuasion utter the mantra of education! education! education! - this must be heard in the residential and nursing home care sector. The good news is that standards, competencies and the quality of care in the sector are improving; but to education we must add environment! environment! environment! As someone who appreciates aesthetics in design we should all be aware of the seductive properties of newly designed and furnished nursing homes (new carpets plus brand new flat screen LCD TVs does not automatically mean multi-dimensional care).

The counterpoint to this are the long stay, geriatric wards of old (c. 1977-1984) and the reaction of family friends when they first walked through the (three) doors.

They were distraught.

In time they came to appreciate the efforts of the staff and the importance of the knowledge, skills and attitude of the ward team. They could understand and see what staff were trying to achieve regards individualised care. Many responded to the open invitation to be part of the team, to get involved. Yes, the environment was far from 'right' (it was terrible), but it's the people on all sides of the care equation that count. It is the same today, but if the care environment is no longer appropriate then people should be moved to a place were their care needs can be met without recourse to anti-psychotic medication. That is why initial and ongoing person-centred assessment is very important.

It is very difficult to predict future needs and yet trying to anticipate them is the primary nursing challenge. If life is a book, then the turning of the page that ends one chapter and starts a-new is a non-trivial transition. That said and make no mistake, it is not for dramatic effect that we describe the behaviour of some individuals as challenging. Drugs are a tool and like all tools it is how they are used in assuring the highest standards of care, retaining personal dignity and maximising whatever quality of life an individual can achieve. Accounting for care interventions including medication is critical. If due diligence cannot be effectively applied in the financial sector then perhaps there is scope for due diligence in the care of older adults*?

*Some clients are under 65 years of age.

Additional links:
[17 Nov, 2009] Alzheimer's Society report: Poor dementia care in hospitals costing lives and hundreds of millions.

http://www.nhs.uk/news/2009/10October/Pages/Antipsychotic-use-in-dementia.aspx

KT-EQUAL event Ageing Research 17 September

I was really pleased to be able to attend this event last Thursday (do check the site as there is an ongoing programme of workshops):

Making the most of the potential of Assistive Technology

This workshop organised in conjunction with BIAS (Brunel Institute for Ageing Studies) will provide a round-up of recent developments in AT and the underlying research aimed at enhancing independence in the home, improving safety and security, extending the use of the car, managing continence, maintaining the body and stimulating the brain.

 

Hosted by: Brunel Institute for Ageing Studies
Sponsored by: BIAS and KT-EQUAL

10:20 Welcome and Introduction, The world of  BIB and older people, Chair for the morning, Professor Emeritus Heinz Wolff, Founding Director, Brunel Institute for Bioengineering (BIB), Brunel University 
10:30 New Service Quality to Support Self-Care, Keren Down MBE, Director of FAST
10:55  Tackling Ageing Continence, Felicity Jowitt, Brunel Institute for Bioengineering
11:20 Refreshments
11:40 From chairs to stairs, Dr Ruth Mayagoitia, Applied Medical Research Group, King's College London,
12:05 "The Companion" - Independence, choice and self-sufficiency, Edward Varney, Brunel Institute for Bioengineering
12:30 Discussion
12:45 Lunch
13:45 Introduction to the afternoon, The world of BIAS and older people, Chair for the afternoon, Professor Mary Gilhooly, Professor of Gerontology, School of Health Sciences and Social Care, Brunel University 
13:50 KT-EQUAL: its mission for older people, Professor Peter Lansley, Director KT-EQUAL, University of Reading
14:00 Older drivers & older IT users: designing new technology, Suzette Keith, Middlesex University
14:25 Safety and Security in Later Life, Professor Rachel McCrindle, KT-EQUAL Consortium, University of Reading
14:50 Tea
15:10 Nourishing the body and saving the soul, Dr Arlene Astell, St Andrews University
15.35 Technology for people with dementia, Eleanor van den Heuvel, Brunel Institute for Bioengineering
16:00 Discussion
16:30 End

As noted above Prof. Heinz Wolff duly and delightfully introduced proceedings and chaired the morning. As a community mental health nurse for older adults and informatics / ICT enthusiast the day certainly proved worthwhile for me. Here are some reflections on two sessions:

While clinical and information standards have and remain a preoccupation for me, Keren Downs' session raised the chicken and the egg problem of standards and quality in the development of self-care and assistive technologies. Keren's presentation highlighted the stasis in design in the older adults sector and the question of how to energise future vision and models for innovation. There was reference to Shaping the future of care together and Common Core Principals to Support Self Care 2008, Department of Health.

Funding inevitably featured - the green paper listing three options:

Partnership - government pays for between a quarter and a third of care costs ...
Insurance - government pays for between a quarter and a third of care costs ...
Comprehensive - everyone pays into a state insurance scheme, whether or not they need care, and everyone gets free care when they need it.

The next slide reminded me of the tilting, table fitted geriatric chairs of old as Keren Downes highlighted the relative stasis in design and need for change for this population group.

While form follows function - can it also stifle innovation? When you consider change in materials, people's homes, care environments, attitudes ... there must be opportunities for innovation?

I also recalled similarities between this market of assistive technology and that of benefits realization within nursing (health) informatics. Especially as barriers were considered such as:

• poor design (usability)
• information provision
• workforce competency
• procurement
• (To which I would add 'value added services' - maintenance, life-cycle management.)

As the speaker and work of FASTUK made clear, older adults represent a growing and emerging market, for whom standards and design will be critical if self-care and assisted living are to be fully realised *.

The final slide listed some reports and a web link as follows:

FAST reports: www.fastuk.org

• Assistive Technology supporting self care, July 2006
• Assistive Technology –Workforce Development, June 2007
• Annual Report to Parliament on Research and Development in Assistive Technology, July 2009

Felicity Jowitt in another session:

TACT3: Tackling Ageing Continence through Tools, Theory and Technology

- provided a concise non-medicalized definition:

Urinary Incontinence 'is a condition in which involuntary urine loss 
is a social or hygienic problem and is objectively demonstrable'.

International Continence Society definition of incontinence

The talk included explanations of the problems and how they arise, prevalence, management, available AT options and the anatomically - stigma driven challenges that male and female continence presents. To close new assistive devices were discussed. The creation and production of discrete, well-designed person- (in a social context) friendly aides, special pads and devices to detect the odour that signifies the need to change a continence pad before the human nose is alerted.

The sessions featured a Q&A session and amongst the many questions raised, I wondered about the ideal of continence aids that also help nurses and carers maintain high quality standards of care and professional values. ... Perhaps from the late 1970s I have antiquated notions of basic nursing care? It is shocking to hear stories of people being told to "do it anyway - you've got a pad on!". Does it not occur to these people that if the person is asking they obviously have insight and are distressed by their urgent situation. As to people who are confused and asking as a result of agitation - the mind boggles and the heart aches at the standards of care evident in such an attitude.

So, this was a really thought provoking and - despite the subjects - enjoyable event and I have only of course scratched the surface.

The majority of presentation (including those above) are available on the download page.

A related reference I am following up:

Duarte, L.R., Marquié, L., Marquié, J-C. et al. (2009) Analyzing feature distinctiveness in the processing of living and non-living concepts in Alzheimer’s disease, Brain and Cognition, Volume 71, Issue 2, November 2009, Pages 108-11.

I will do a h2cm matrix on continence in the future.

* You can almost hear the critical exclamation of a future aged '60s generation - "No way dude I'm not using that!". Perhaps by then we will have the means to ensure they retain the faculties to pass a critique.

'Relative' poverty (4) - sociology

[The introduction is repeated across these posts: intrapersonal, political, sciences]

There are many paradoxes in life and many of these are concentrated in the realm of health and medicine (a major sub-division of life and death).

For decades the link between poverty and standards and quality of health has been recognized and politicized in the media and policy. In June there was news of a Bill to make the eradication of child poverty a legal obligation not something that can be the political objective at the start of a Government and then cast aside.

Many things are relative and poverty is often described in this way applying to individuals, social classes, communities, regions and whole nations. Using the domains of Hodges' model what reflections does this prompt? Let us see:

SOCIOLOGY: A key resource we all ordinarily rely upon is that of family, friends and community. While a source of stress at times as in you can choose your friends, but you can't choose your family..., and then there's the history of psychosocial intervention; the family is nonetheless usually seen as the asset.

Social poverty - having no (immediate, accessible) next of kin, friends or social network has been identified as a key deficit that may result in negative outcomes and problems in rehabilitation, recovery and staying well. There is an expanding literature on the role of social networks. Despite the current emphasis on e-social networks the interpersonal form of social network remains pivotal as a key strength for people to deal with major challenges to their health, social care and well-being.

The socio-economic contribution of informal carers is well recognized and vital in the management of long term medical conditions ('self-care by proxy'?). 'Caring' and carers predates what we today call 'nursing'. Carers shoulder a care burden saving the State an enormous sum of money. Within Hodges' model this domain - the SOCIOLOGICAL - may be a remote cousin, far from the sciences, but the fuzzy logic here is predicated on families and relationships.

In the social domain the whole community can act as a pool of kinetic and potential energy, a resource - locking up wealth in knowledge and skills that can counter social poverty and periods of self-neglect should this occur. The future health and social care agenda depends upon the workforce being able not only to create this social wealth, but ensuring people are able to release this knowledge. Physics, energy, time - there is no escape. Perhaps assumptions as per this quote* also have a role to play -

‘‘Of all the self-fulfilling prophecies in our culture, the assumption that ageing means
decline and poor health is probably the deadliest.’’
Marilyn Ferguson,
The Aquarian Conspiracy, 1980

Additional links:

Relative poverty, absolute poverty and Social exclusion - poverty.org.uk

World Poverty - Social Poverty

'Poverty' on W2tQ

Sociology care (knowledge) domain links resource

Biblio:

*Sirven, N., Debrand, T. (2008) Social participation and healthy ageing: An international comparison using SHARE data, Social Science & Medicine, 67, 12, 2017-2026.

Mitchinson, A.R., Kim, H.M., Geisser, M., Rosenberg, J.M., Hinshaw, D.B. (2008) Social Connectedness and Patient Recovery after Major Operations, Journal of the American College of Surgeons, 206, 2, 292-300.

Relative poverty (3) - sciences

[The introduction is repeated across these posts: intrapersonal, political, sociology]

There are many paradoxes in life and many of these are concentrated in the realm of health and medicine (a major sub-division of life and death).

For decades the link between poverty and standards and quality of health has been recognised and politicised in the media and policy. Just this past week was news of a Bill to make the eradication of child poverty a legal obligation not something that can be the political objective at the start of a Government and then cast aside.

Many things are relative and poverty is often described in this way applying to individuals, social classes, communities, regions and whole nations. Using the domains of Hodges' model what reflections does this prompt? Let us see:

SCIENCES: We tend to think of economics and the definition of poverty in materialistic and monetary terms. In this domain things become things. Processes and much more besides - people are objectified and commodified: prostitution, child labour, child soldiers, people trafficking - individuals as numbers at a certain time, certain place. The person reduced to a process - service.

On the sciences front in an explicit way our poverty of knowledge ('education, education, education') becomes apparent as we try to place value on the environment and not only our personal use, but national use of the green and blue. A new economics is indeed called for.

In the current 2009 Reith Lectures (closing lecture this week) Professor Michael Sandel presents A New Citizenship. Within these lectures Prof Sandel explains how fees change services, values and expectations with examples of child care and blood supply in health care. Organisations have to be aware of their assets with laptops, PCs and umpteen other pieces of equipment and resource possessed of their own unique ID.

Yes, according to my interpretation of Hodges' model the points raised here belong in the political domain, and yet we are so befuddled, intoxicated and to a certain extent deluded with the sciences, technology and material things (de-vices?) that in contemplating poverty we must extend the political realm. ...

From now on the public's attitude to science as individuals and families, communities and nations is going to be critical to change our understanding and more importantly our experience of poverty - material, relative or otherwise.

Image source: BBC

Additional links:

The Simonyi Professorship: hair for the Public Understanding of Science at Oxford University

'Poverty' on W2tQ

Sciences care (knowledge) domain links resource

Political care (knowledge) domain links resource

Relative poverty (2) - political

[The introduction is repeated across these posts: intrapersonal, sciences, sociology]

There are many paradoxes in life and many of these are concentrated in the realm of health and medicine (a major sub-division of life and death).

For decades the link between poverty and standards and quality of health has been recognised and politicised in the media and policy. Just this past week was news of a Bill to make the eradication of child poverty a legal obligation not something that can be the political objective at the start of a Government and then cast aside.

Many things are relative and poverty is often described in this way applying to individuals, social classes, communities, regions and whole nations. Using the domains of Hodges' model what reflections does this prompt? Let us see:

POLITICAL: Although we are told that change is happening swathes of humanity face -

poverty of choice or no choice but poverty.

There are those who are able to decide and yet denied choice due to a politics or state that spits explicit corruption denying the people their expressed and collective will. Although previously described as 'black and white' politics must become participative AND must become 'green and (truly) global'. As events in 2009 attest here in the UK, politicians, those key workers / case practitioners in this domain (should paradoxically) disavow personal ambition and at times yet to be decided the party whip system. Yes, these matter, but again space (vacancy) is needed to accommodate - permit and facilitate true focus.

This is no chance opposition of domains in Hodges model.

The diagonal of INTRAPERSONAL and the seat(s) of power and governance
is mediated through the social domain.

Like health professionals, politicians and civil servants must wipe the slate clean: constantly. This is why transparency in politics is so crucial to trust, engagement, and grounded politics. ...

'P' is for politicians not just the 'people'.
Politicians need to be engaged coherently.
Touch is the interface for them too.

A week is a long time in politics because the sun never shines (not even in 'victory'). For these people being open, transparent, non-judgemental ... means their vision is refreshed by a perpetual rain.

Only then will they see poverty and be reminded of it -
even if poverty and even more so if poverty
represents where they came from ...

Image source: Equator Network

Additional links:

Reith Lectures 2009 BBC 'A New Citizenship'

'Poverty' on W2tQ

Political care (knowledge) domain links resource

Relative poverty (1) - intrapersonal

There are many paradoxes in life and many of these are concentrated in the realm of health and medicine (a major sub-division of life and death).

For decades the link between poverty and standards and quality of health has been recognised and politicised in the media and policy. Just this past week was news of a Bill to make the eradication of child poverty a legal obligation not something that can be the political objective at the start of a Government and then cast aside.

Many things are relative and poverty is often described in this way applying to individuals, social classes, communities, regions and whole nations. Using the knowledge domains of Hodges' model what reflections does this prompt? Let us see:

INTRAPERSONAL: On one level highlighting poverty here appears a nonsense as usually we think of material wealth; the ability of people to be able to put decent quality - nourishing food on the table. In the miserable trap that poverty presents, it is perverse to suggest that health and social care workers - indeed all 'customer facing personnel' seek poverty. But they should exercise: poverty of thought.

Health and social care are often couched in terms of being a safety net, especially in community care - this conception emphasizes health and social care as a physical resource. In the intra-interpersonal domain though we are concerned with individual mental life, beliefs, attitudes, thoughts and emotions....

So here it is as if we must adopt the philosophy of Bruce Lee and turn the 'art of fighting without fighting' into the 'art of caring without caring' through a momentary forgetting in order to care effectively. We suspend our thoughts - take a mental breath, bring our training and current evidence to the fore. The conceptual safety net does not work if it comes pre-filled with bias, prejudice, pre-conceived ideas and negative expectations. There is of course a very poignant irony in calling for people to forget, suspend belief - even for an instant - at this time and in this domain. For health and social care workers in wiping the slate clean we do not think, but are VERY receptive to what follows.

This is where the wealth is:
between us.

We should not play the greedy capitalist and keep collaborative tools like Hodges' model to ourselves.

It was made to share: in my mind and yours a global health resource...

Image source: BBC

safety net: http://blogs.jamaicans.com/metinking/2009/04/30/a-jamaican-legacy-that-deserves-our-support/

Additional links: 'Poverty' on W2tQ

Political care (knowledge) domain links resource

COMMENT - 22 June 2009:

Would this article of mine along with its rapid responses add to your discussion?

http://www.bmj.com/cgi/content/citation/325/7354/51

http://ukpmc.ac.uk/articlerender.cgi?artid=478323 (full text)

Would you like to send me a book chapter on your experiences with the Hodges model in healthcare?

http://www.igi-global.com/requests/details.asp?ID=...

Regards,

Rakesh
Rakesh Biswas

Hello Rakesh,

Many thanks for your input and invitation. I don't think I could make the deadline for the book which is a pity, I've completed two book chapters for IGI thus far. The website is priority and Drupalcon Paris. I will think about this though and e-mail you soon - or please contact me directly at h2cmuk at yahoo.co.uk.
I've another three posts with this title. The post above rather grew to stand alone.
Anyway thanks again your input is most welcome and appreciated.
Regards
Peter

Nursing Times: Safety ytefaS :semiT gnisruN

This weeks Nursing Times includes an article by Liz Owen 'Improving compliance with the C. difficile root cause analysis tool' (2009). The piece includes a section that highlights* the importance of reflection, which together with action planning underpins the concept of root cause analysis (p.16).

There are three references in particular cited: Murphy (2002) in relation to the infection and prevention team giving leadership to staff committed to reducing health care associated infections (HCAI) rather than accepting sole responsibility for HCAI. This also entails capturing the 'hearts and minds' of staff (Shapiro, 2003) completing the root cause analysis tool (p.16). Amongst many interesting points - it was found that there were unexpected benefits too (Glanfield, 2003) notably - strengthened relationships and improved attitudes.

This reminds me of affordances in human-machine interfaces and the use of technology more generally. As Owen and others show whatever we call these unexpected outcomes they are by definition unexpected, or not readily accessible to our initial perception and reasoning. Owen found that clinical engagement and leadership proved central in this project. Is there a way to foresee more of the 'unexpected' whether barriers or benefits?

Before being able to engage with others we need to be aware and able to -

reflect on our own hearts and minds.

A coherent team with the inevitable chaotic-creative outliers that (just 1 or 2....) personalities bring might just help us see around the corners - an additional key asset to safety...

Murphy, D.M. (2002) From expert data collectors to interventionists: Changing the focus for infection control. American Journal of Infection Control; 30: 120-132.

Shapiro, A. (2003) Creating Contagious Commitment. Hillsborough, NC: Strategy Perspective.

Glanfield, P. (2003) Towards sustainable change and improvement. In: Pickering, S.P. (ed) Clinical Governance and Best Value. London: Churchill Livingstone.

Owen, L. (2009) Improving compliance with the C. difficile root cause analysis tool. Nursing Times; 105: 16, early online publication.

*even if that is just a subtitle?

A techno-spiritual world with agnostic needs

Whatever our own personal beliefs
we live in spiritual times.

Agnosticism
is a frequent and ongoing subject of debate in
the philosophy of religion, science and ideas.

It also features - duly tempered for purpose -
in other fields notably technology.

In the early days of IT and ICT those buying information systems grew tired and wary of being locked-in to particular platforms, with consequent dependency upon vendors. This also put the technology to the fore, with the risk of relegating business requirements to 'out of hours'. While many business relationships did undoubtedly prosper, the market soon recognized the need for standards and the need for technology to be agnostic, increasing freedom and choice in the marketplace.

Among the retinue of central tenets in medicine, health, social care and nursing is the need for unconditional positive regard and a non-judgemental approach. So caring is most definitely not without beliefs and values. In the same way that vendors to companies and academia want to be free and determine their requirements around their business and needs, so too there is a perceived need for the health care 'industry' to be agnostic. Re-framing a bullet list in the post: ''Increase knowledge innovation and manage technology change' c/o http://lucasmcdonnell.com/ agnostic in a health context becomes:

1. As per the need for evidence-based x, y, z... fully research your status, direction and tools not only before you adopt them, but also while you’re using them*;
2. Don’t get emotionally attached to a particular assessment, planning, intervention (therapy) or evaluation toolset;
3. Continuously research (horizon scan* - look over the fence) at other research possibilities and alternatives;
4. And as Lucas McDonnell make clear: Don’t build yourself into a corner*.

*Of course, that last point is hypercritical - since there are at least four corners!

This is where Hodges' model comes into play, (not quite with underpants on the outside, but certainly with utility belt firmly in-situ).

Hodges' model - as a model to support and integrate care - is agnostic in the following ways:

DISCIPLINE: unless its origins prejudices its case, Hodges' model can be applied by any and all disciplines. This is crucial in times when multidisciplinary and even transdisciplinary team work is needed.
THERAPEUTICS: whether physical, social or biopsychosocial - Hodges' model is agnostic regards particular therapy interventions. It is not married to gene therapy, cognitive therapy, primary nursing, family therapy, gestalt therapy.
PHILOSOPHY: 'care- nursing- ward- philosophy' is probably a much misused term, but once again Hodges model is philosophically neutral - unless it is deemed that its generality - pantological aspirations - is itself a philosophical stance?
SUBJECT: in being person-centered the model is agnostic in respect of the individual using the model or who happens to be the focus of the model. This is quite critical at present with the engagement of patients in education, self-care and individual budgets in cases of long-term medical conditions.
AUTHORITY: Although disciplines with their professional legacies and politics can and do (justifiably) lay claim to authority and legitimacy Hodges' model can negotiate this divide.
SOCIO-TECHNICAL: this form of agnosticism for Hodges' model is not given the credence it should be afforded. Being context sensitive and situated the model can perform a definitional volte face appealing to a socially or technically oriented user-base, or both.
CULTURAL: Finally, it is essential that our tools are not 'tainted' from the perspective of a particular community or ethnic group. Apart from the structure of the model with its historical (mythic) iconographic associations, the model is open and not directly allied to any specific ethnic group, set of cultural or religious beliefs. Ideologically AND practically then the model provides a neutral ground upon which values and beliefs can be shared.

Additional links:

Becoming a Technology Agnostic, by davidleeking (My primary source through twitter)

Increase knowledge innovation and manage technology change.

AAPT: a technology agnostic strategy - interview with Dave Marsh, Director of Infrastructure Solutions - Interview.

Technology-agnostic approach to Service Oriented Architecture: back to the essence of SOA?