2011... looking ahead: Line of sight - Lines of insight

LINE OF SIGHT:

LINES OF INSIGHT:

Fractal Drum

Image sources:

Wilkinson, F.J., Monkhouse, H. R. (1967). Maps and Diagrams; Their Compilation and Construction [Paperback], Methuen & Co Ltd. Intervisibility, Line of sight. p. 125 [scanned].
(Book purchased in Mevagissey, Cornwall, Hurley Books July 2010)

Fractal drum. Lines of INsight: http://classes.yale.edu/fractals/panorama/ManuFractals/FractalDrums/FractalDrums.html

Health and social care - listen!

Lean machine(s): chasing the contexts

There is a perennial game in health and social care called assessment and evaluation: the game could also be called 'CTC' - 'chasing the context'.

Relativity lies not only in the realm of physics and philosophy.

When I say relativity I am referring of course to the influence and impact of a health and social care situation from the constantly changing perspective of each of several different players:

• the patient;
• carer;
• nurse;
• doctor;
• manager;
• medical ward;
• community mental health team;
• commissioner.

Usually, the context collapses to a specific problem (a situation) and the players set to solve a care problem presented by an individual -

• a client, resident or patient;

and their -

• relatives;
• residential care home manager;
• residential care home staff nurse and team;
• community mental health nurse;
• medical personnel.

Context directs, dictates, and shapes health and social care theory, practice, management and policy.

This relativism can also subvert, sublime, confuse and stymie plans, common sense notions, creativity, innovation and management directives.

Like a tide this relativity picks us up and re-figures, re-paints and shifts the location of everything - including measures and how they are used.

Context is all! - so the saying goes. But context never wholly reveals itself. For that is another situation, another context, another side, another coin.

For context there are key defining parameters (location, diagnoses, risk, need, physical, mental, holistic ...) all of these are couched or spring from time.

So, the game calls for us and the tide teases us to measure and evaluate. This coast is never clear, but how long is it now? Where are the pathways now? Where will they be again?

As we travel (and travail) to and from this context to that - thresholds are also altered: up and down and always around; the way of life and ..... .

Image source:
http://www.esd112.org/edtech/no_limit/rs_archive.cfm

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

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

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

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

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

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

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

The bold text below is my emphasis:

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

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

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

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

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

Regards,
Rakesh

Here is a quote from the paper:

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

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

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

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

Journal of Evaluation in Clinical Practice

Dear All,

I’m pleased to advise you that the next edition of the forum has been published in the Journal of Evaluation in Clinical Practice. I hope you enjoy the ongoing efforts of all our contributors and will be encouraged to submit your next manuscript to the journal.
With kind regards
Joachim and Carmel
Co-editors

Volume 16 Issue 3 (June 2010)

Editorial

Variability, continuity and trust – towards an understanding of uncertainty in health and health care (p 401-402)
Joachim P. Sturmberg
DOI: 10.1111/j.1365-2753.2010.01458.x

Original Articles

Homeostasis and Gauss statistics: barriers to understanding natural variability (p 403-408)
Bruce J. West
DOI: 10.1111/j.1365-2753.2010.01459.x
Abstract
Music in the Park. An integrating metaphor for the emerging primary (health) care system (p 409-414)
Joachim P. Sturmberg, Carmel M. Martin, Di O'Halloran
DOI: 10.1111/j.1365-2753.2010.01460.x
Abstract
W(h)ither complexity? The emperor's new toolkit? Or elucidating the evolution of health systems knowledge? (p 415-420)
Carmel M. Martin, Margot Félix-Bortolotti
DOI: 10.1111/j.1365-2753.2010.01461.x
Abstract
Power law relationships between health care utilization and symptom assessment among people with panic attacks (p 421-426)
David Katerndahl
DOI: 10.1111/j.1365-2753.2010.01462.x
Abstract
Social factors in clinical complexity: reflections from a paediatric unit (p 427-430)
Shruti Sarkar, Dipankar Sarkar
DOI: 10.1111/j.1365-2753.2010.01463.x
Abstract
How do primary care doctors deal with uncertainty in making diagnostic decisions? : The development of the 'Dealing with Uncertainty Questionnaire' (DUQ) (p 431-437)
Antonius Schneider, Bernd Löwe, Stefan Barie, Stefanie Joos, Peter Engeser, Joachim Szecsenyi
DOI: 10.1111/j.1365-2753.2010.01464.x
Abstract
Joachim P Sturmberg
Prof. of General Practice
PO Box 3010
Wamberal, NSW 2260
Australia
http://monash.academia.edu/JoachimSturmberg
The core value of medical care is the improvement of personal health, the value inherent and constant since the beginnings of medicine, and the achievement of personal health depends on an ongoing personal relationship with the doctor. - The Foundations of Primary Care. Daring to be different.

Have workspace, workbench - let chaos ensue

Whether trying to write computer programs, engage in woodwork, artwork or needlecraft the workspace that you need is critical to what follows.

Having a dedicated workspace is the sign of a professional.

If these activities are purely a hobby you may need to create the space on the fly. Getting the easel and paints out, protecting the carpet and then after all those creative juices are spent you have to organise the clean-up.

The Health Career Model can provide a workspace: a dedicated one. So if like many researchers your focus is (global) health, nursing, social care and social policy ... Hodges' model can provide an assurity space. Whatever your approach here is a great way to explore the scope and boundaries of your plans, objectives and final outcomes.

I noticed a letter by Fawcett et al. (2008):

We congratulate Chaffee and McNeill on the publication of their article, “A Model of Nursing as a Complex Adaptive System” (Nursing Outlook 2007; 55:232-241). The development of a new conceptual model of nursing always is a cause for celebration of the advancement of our knowledge. We are, however, concerned that Chaffee and McNeill did not place their conceptual model within the context of or show an evolution from relevant existing nursing conceptual models. We refer readers to Holden’s¹ concept analysis of complex adaptive systems. She explained the relevance to nursing of the concept, complex adaptive systems, by tracing the “rich tradition” of systems thinking in nursing and pointed out that nurse theorists, including Dorothy Johnson, Imogene King, Martha Rogers, and Callista Roy, have developed conceptual models of nursing that reflect systems thinking. Holden concluded, “This rich tradition in nursing that has emphasized connections and interactions within a systems paradigm continues today. Complexity science merely represents the next stage in understanding how systems operate.”¹

Jacqueline Fawcett, RN, PhD, FAAN
Professor, College of Nursing and Health Sciences, University of Massachusetts, Boston.
Jacqueline Fawcett, Elizabeth Ann Manhart Barrett, Barbara W. Wright, Letter to Editor, Nursing Outlook, Volume 56, Issue 2, March-April 2008, 49.

REFERENCE
1. Holden LM. Complex adaptive systems: Concept analysis. J Adv Nurs 2005;52: 651-7. Nurs Outlook 2008;56:49. doi:10.1016/j.outlook.2008.01.003

Whilst explanations of systems have an essential place in understanding nursing, for me the concept of primary interest within (and without) systems is information. This is not just symptomatic of the paradigm of our times, but a fundamental facet of not only engaging leading edge (quantum) sciences, but relating nursing, complexity, systems, art and science to patients, carers, citizenry and global (eco-) health.

If this appears a recipe,
which when executed on the workbench will result in indigestion,
- have faith -
the problems of our times demands a framework with a massive conceptual maw.

So, in turn I would request that future nurse and complex systems researchers look further afield and factor in the need for and use of a high-level global (ethnoculturally agnostic), universal (multidisciplinary, objective, subjective) workspace:

One with sufficient bandwidth.

Having a dedicated workspace that can be shared across disciplines
- that is multidisciplinary -
denotes a mature profession
and a 21st century professional.

Image source: With thanks to Chunx.com 'Chaos Field'

Additional links:

Nursing Theory Link Page

W2tQ: chaos

W2tQ: complexity

'assurity space'

Information: See bibliography.

Jones, P. (1996) Humans, Information, and Science, Journal of Advanced Nursing, 24(3), 591-598.
Jones, P. (1996) An overarching theory of health communication? Health Informatics Journal, 2,1,28-34.

Notes (III) for a 2010 introduction to the Health Career Model

Definition through purpose

The original purposes for the model's creation are as relevant today as they were in 1983-84:

1. To produce a curriculum development tool;
2. Help ensure holistic assessment and evaluation;
3. To support reflective practice;
4. To reduce the theory-practice gap.

Items 1-4 plus safety are all dependent in one way or another upon knowledge. Admittedly, this is a case of stating the obvious and something of a non-statement in that everything comes down to being knowledge (or nonsense). Resort to some global notion of 'knowledge' amounts to non-differentiation and this tells us nothing. On the contrary: this is how the simplicity of Hodges' model can cultivate and give rise to global complexity. This can help explain the model's potential and utility as a cognitive tool, an aide memoire, a mental prompt and structured conceptual checklist to frame:

• thought
• knowledge (ontology)
  
• perspectives
• dialogue
• problems
• strengths - weaknesses
• plans and actions
• outcomes
• and much more ...

Whether student or specialist practitioner various conceptual elements and (care) threads can be acquired, constructed, integrated and mapped from the dual (in-situ) worlds of theory and practice to the cognitive (personal - reflective) and virtual [cogeographic?]. This means the model can be used as a mental prompt helping to inform theory as in a lecture and subsequent essay; or practically during an interview or care assessment. Beyond this cognitive application, the model's produced can then also be captured and represented on paper, or as an electronic record - by various user communities. ... (Notes IV to follow)

[These are notes. If you have any thoughts, views on a new introduction to the model please get in touch:
h2cmng @ yahoo.co.uk What do you feel needs to be explained? Which audience should be addressed in the first instance? What assumptions can be made? ....? Many thanks PJ ]

Notes I intro for 2010

Notes II intro for 2010

Notes (I) for a 2010 introduction to the Health Career Model

.... The structure and composition of Hodges' model can be viewed as a sketch, a back-of-the-envelope idea expressed as a diagram as per (insert figure 1 and 2) and in combination (figure 3). While this is a perfectly valid interpretation it invites the view that Hodges' model is simplistic. In its basic unpopulated form the model is simplistic, in the same way that a blank canvas, computing device display, or piece of paper is simplistic. There is however, much more going on here, consideration of which can lead us to new ways to justify and explain the model.

"Make everything as simple as possible, but not simpler"
Albert Einstein

Einstein is helpful because while simple - the model provides the foundation for global conceptual scope (complexity) should this be needed. Hodges' model demonstrates the complexity of health and social care without making it simpler.

"Simplicity means the achievement of maximum effect with minimum means."
Dr. Koichi Kawana, Architect

If Hodges' model is simple, a way to represent the tip of the health and social care iceberg, then why should we then wish for global conceptual scope? The reasons are manifold, but revolve around one factor:

safety.

...

Quotes source: http://www.petefreitag.com/item/496.cfm

Foundations, projects, corners and cornerstones

Ok, so you have a new project - that's great!

Yes, we are going to build something - outstanding!

Sounds absolutely marvellous!

We are going to use up-to-the-nanosecond project management tools.

And you're going to do it by the book, charts and real-time tags.

Yes, with a dash of intuition plus - you know - gut instinct!

Well sure, pleased to hear that too.

We will take account of history, learn the lessons -
we've a researcher onboard you know?
Building a world-class team that's all fleet of foot and mind.

We'll tick all the boxes, check all the corners and leave no stone unturned.

Truly admirable, but how many boxes and corners have you got and how many cornerstones* will you need?

Eh?

Hey listen up. Corners are for losers,

naughty children

and people lost in the dark.

Nobody is going to be stuck standing in the corner on this one!

Oh - right.

Well good luck....

Image sources:
'Cornerstone office': Cornerstone Corp. Center
Dan Flavin: at Artnet.
Inspired by the word 'cornerstone' and Untitled (Corner Piece) 1969 on visit to Tate Liverpool, 25 September 2009 (not the piece illustrated above):

Flavin made a number of works intended to be shown in corners, engaging directly with the architecture of the gallery. His use of commonly available fluorescent tubes enabled him to explore light as a non-physical material, animating gallery walls. The size of the work was determined so that the units could be fastened in the centre only, without having to be anchored to the floor. The artist rejected any symbolic significance of the object, insisting that it was simply a form that made good use of a corner.

Question: How many corners are there in Hodges' model?

*Cornerstones: here referring to stakeholders, sponsors, owners, partners, investors, builders, architects, designers...?

NHS: Welcome to the world of churning?

In February (hey, give me chance - I am part-time!) in the HSJ was a news item about the NHS Constitution which warned of the huge bill that looms in the need to provide choice information for patients. Quoted figures c/o health economists at the Department of Health put "the best case scenario of a cost of £5.2m per year (£33,000 per PCT) 5.5 per cent of patients would need to switch providers".

We are all accustomed to switching providers when it comes to telephone, gas, electricity, TV, internet-broadband in various combinations. Some 'real' markets need their business models to recognise and take account of the fact that a proportion of the market switch service providers - in other word they churn.

You have to ask I suppose are the +ve and -ve qualities and impact of churners in these markets equivalent to those in health and social care? The future is a place and time of complex deals no doubt...

Crump, H. (2009). Huge bill looms for choice information, HSJ, February 5, p. 5.

Study the hoops, but care about the thresholds

When you are on a course you really have - quite rightly - to do things by-the-book. That is the way - they say - you learn which corners of the pages you can turnover. Students learn early on that you have to jump through various hoops in order to complete the course and earn the stripes. The art and science of caring presents its own hoops, but in addition it is thresholds that present a barrier, thresholds that need to be negotiated in order to meet need.

Suddenly this is not about one person (you) it is about a partnership. A partnership of professionals allied and directly collaborating with a 'patient' and their carers.

One of the hoops is the paper or electronic referral form. Are you still sure this referral of yours is necessary? Are those two assessments really necessary?

There are a host of thresholds that may (or may not?) shift like a tide around the local and increasingly extended health and social care community, or 'economy' if you prefer, for example:

The threshold at which a nursing home will contact a GP surgery; or mental health services?
Just exactly what is residential care's capacity to cope internally and manage with a given range of health and social care challenges? What exactly should that capacity be? Should the public have access to referral data from care homes - to accident and emergency, mental health services, primary care? What proportion of 'referral problems' are dealt with at the nursing - social work level? What is the mental health service's threshold in terms of responding to a referral? What is the threshold for relatives believing that sufficient is being done for their loved one?

As lifelong learners of course we are all perennial hoop jumpers, learning the art of scaling and re-framing the thresholds that cross our way.

Image sources:

Seed-and-threshold segmentation

hula hoop