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!

Caution! spanning the Theory - Practice Gap

As a new academic year begins and we endeavour to bridge the theory - practice gap we need to be cautious:


While we may not burn our bridges we need to be aware of which bridge spans are redundant and which are still active and serving their purpose.

As ever - standards, inspection, audit and governance are critical.

So in our efforts to bridge the theory - practice gap do we also maintain it?

Cost savings: 4-fold literacy = care literacy

The RCN's campaign I posted yesterday highlights the belief in and potential of nurses to 'think out of the box'.

There are many people, in many walks of life who are currently racking their brains and flipcharts to come up with ideas for cutting costs. In addition to the RCN, the government has its on-line campaign with the 'Spending Challenge'.

As for nurses there is an extra rabbit to pull from the hat: improving patient care.

Media discussion about the cloned beef - food supply story this week brought a point regarding the relative scientific literacy of the general population of USA and UK. This prompted me to consider discipline based literacy, what usually passes for 'basic grounding in ...' or competency. ('Literacy' has already been corrupted, now for another kick.)

For nurses with their subject disciplines, which can be represented in the health career model - what current public sector health (and social) care requires (demands!) is care literacy.

It is the ability of nurses (and other professionals) to be aware of what happens in the two adjoining boxes, or that one remote enclosure that can simultaneously engender and deliver:

• new insights - creativity and innovation;
  
• holistic integrated care;
• care literacy;
• and - cost savings that can still improve patient care.

See also:
http://hodges-model.blogspot.com/search/label/literacy

Editorial JRN. Coalition in leadership: Politics - the big picture and the big game

In the Journal of Research in Nursing, Veronica Bishop's editorial -

Coalition in leadership.
Politics - the big picture and the big game

- explores the state of the body politic in nursing. Bishop's focus is research, but the implications extend beyond the UK, to nursing globally. The body is indeed immersed in politics, but it seems the feet are dry and there is no one at home.

Considering that The Politics of Nursing by Jane Salvage was published c. 1991 political maturity is long overdue?

While the sexual politics of nursing have been campaigned for in the nursing media and vigilance is needed, it seems that a political birth for nursing needs to be induced. There is a political mentality there, there has to be. The future is too challenging, too fraught, too close to be mollified by appeals of "Anything for an easy life (and death)!."

Bishop begins with a quote:

The very essence of leadership is that you have to have a vision. It’s got to be a vision you articulate clearly and forcefully on every occasion. You can’t blow an uncertain trumpet.
Theodore Hesburgh (1917–)

If you are familiar with the health career model then you know what is coming. ... In quantitative terms 25% of our deliberations using Hodges' model can be POLITICAL. This is not just the political dimensions of the patient, carer and the health and social care enterprise. The model includes the practitioner, but back to Bishop:

Having ‘power’ is a concept that sits uncomfortably with many nurses – it does not fit with the ideal of caring and many clinical nurses are quite open in their lack of regard for those in management, seeing them as power-seekers rather than power-movers. Clearly nurse leaders have in many cases failed to take their clinical colleagues with them in the drive to put nursing where it belongs, at the decision-making point that drives the agenda for health services, a point borne out by Stanley (2009).

How ironic that 'comfort' itself has been the subject of concept analysis and theorising in the nursing literature. If student nurses are exposed to the POLITICAL from the outset of their careers, then surely at the very least they will be more comfortable dealing with the guises and disguises of power?

Bishop refers to leadership and ownership and the two are frequently conjoined. The question of politics in nursing - in thought, practice, management and policy (research!) - makes me wonder ownership of what?

If the political domain is so frequently a vacant lot as far as nurses are concerned, then perhaps when we do put in an appearance we are not taken seriously. It really is a case of: what are you doing here?! As Bishop points out through -

Nurses are scientific. When they want to get to the core of a problem they always try to drill down. Yet politics are about the big picture. Nurses are agriculturalists in that they grow and nurture things but politicians are hunters – they’re always after the big game. It’s these kinds of differences nurses need to start to understand. (Cumberlege, 2007).

Nurses are there in the POLITICAL domain: they are constantly trying to complete the big picture.

... we were considering the best way for her [Baroness Cumberlege] to approach an interview the following day, and eventually, after we had viewed the uppermost issue of the day from every angle she said ‘Oh, nursing is so big!’. How right she was – there is hardly any aspect of life that it does not overlap or impinge on, so considering the big picture is a mammoth task! And again, she was right, we need leaders who have clarity and energy, and can cut through the detail and focus on the professional entity.

Yes, the big 'P'-icture is a mammoth task, hence the need to uncover, compose and frame it early. POLITICS is not just a matter of whistle blowing, industrial relations, policy, the system, us-and-them, banner headlines. ...

Politics is much more and crucial to research as Bishop attests. So, if our students do not reflect upon and articulate the politics of health: ill-health, well-being, equality and inequality, wealth and poverty ... then that professional entity will be a political ghost. A ghost playing a little game in an alien and alienating domain.

Veronica Bishop (2010) Coalition in leadership. Politics - the big picture and the big game, Journal of Research in Nursing; 15; 291.
DOI: 10.1177/1744987110374692

The cost of anholistic care

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

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

Advanced discharge planning is many things:

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

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

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

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

Apparently -

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

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

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

Holistic bandwidth (and the dangers) of political care

The attack on MP Stephen Timms here in the UK highlights not only the ongoing importance of personal safety for public service personnel, but how much politicians value their constituency work. It is no accident that these sessions are called "surgeries".

The politician meets not just a citizen, but a political obligation and duty to care. In the media reports it was interesting to hear of how much satisfaction MPs get from their constituency work. Listening to the reporting and debate prompted me to realise that although politicians vary in how well they engage and empathise with their constituents the problems they are asked to deal with covers a broad holistic spectrum. Consider this listing written by Tony Wright MP:

• The education system
• The transport system
• The social services
• Health services
• Housing
• The environment
• Government bodies
• The justice system
• Immigration and asylum
• Finances and employment
• Trade unions
• The media

I am a community nurse five days a week.

Our MPs are community politicians one day a week with 'Constituency Friday'.

So to The Rt Hon. Stephen Timms (and his staff) I wish you a speedy recovery and congratulations on the extent of you and your peer's constituency work.

Holistic in a word and deed.

Congratulations also to the Green Party on the success of their leader Caroline Lucas MP.

The Health Career Model: POLITICAL domain resources

Holistic interferometry

Since Galileo first pointed a telescope at the moon, the instrument has evolved with bigger lenses and mirrors. Despite additional advances in optics, physical constraints eventually prompted development in other directions. Rather than one optical or radio telescope, why not combine the inputs of several, tens, hundreds... ?

The health career model can act as an interferometer
for health across the care spectrum*.

We desperately need holistic interferometry for the personal, social, community (urban, rural and nomadic), national and global health care challenges we face.

* Which includes much of the electromagnetic.

Links:

Interferometry: Space.com

Plateau de Bure Interferometer (PdBI)

Allen Telescope Array

SETI@home

Seti Inst.

LIGO, the Laser Interferometer Gravitational Wave Observatory

Image source: Seti League
http://www.setileague.org/array2k/array2kb.jpg

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.

Nursing and care homes: the new schools 4 basic nursing care?

I do not wish to denigrate the quality of care in nursing homes, as I've blogged previously there are others better placed to do that when needed. In some the nursing care is exemplary and this is evident not just in their inspection rating, but the morale of staff, the reports of relatives and local community plus other indicators - especially when you visit and use your senses. As a nurse you are duty bound to assess the quality of care wherever your practice takes you. In the homes where the care is very poor, there is no escape from that reality. The reality of poor care first hits visitors when they smell the home they have entered. If there is no escape for them - well what then of the residents and staff?

Now an extended and dedicated role for nursing home liaison within community mental health nursing has arrived* and taken root, this must say something about the quality of care in this sector (and not merely suggest a shortage of Consultant Psychiatrists)? Nurse, service managers and commissioners recognise that if they do not preempt the referral torrent (or trickle from some care homes!) then community teams will grind to a stand-still. Care homes need assistance even as private businesses in assuring their holistic competency.

If services do not stem that referral flow as a wave or otherwise, they will in turn become second rate first-aiders with no primary purpose. They will be forced to respond repeatedly to the same client RE-referrals, the same set of disjointed, fractured physical:mental:social health problems presenting in a series of unique individuals. And this is not person-centred care.

What the nursing home liaison role says is that here is one place we can locate the theory-practice gap, a skills gap and a lack of integrated, holistic person-centered care. Mash-ups may be desirable in the virtual world, but in care delivery - is that safe? Too frequently the mash-up of combined physical and mental health problems pass staff by. The problems go unrecognized, they are there: evident, but disguised; due to lack of comprehensive observation, life histories and despite the question and answer sessions at the gates (service interface). However it is described (e.g. single point), the specialisation of community mental health teams into memory assessment, intermediate, community mental health, ... depends on the vibrant management and quality of referrals.

Much is made of nursing homes registered as EMI (Elderly Mentally Ill) and their need for or access to a registered mental health nurse (RMN); but RMNs in turn rely on the ability of more junior staff to observe and accurately report the basic aspects of the resident's physical and mental state. If equity for older people in care is to be achieved, then although the care - nursing home sector is 'private' and a 'business' there must be an accommodation, a partnership when it comes to education and valuing time invested in these homes.

*Additional links:

http://www.careinfo.org/congress/pdf07/07par.1340q2-joannehirst.pdf

http://www.mentalhealthequalities.org.uk/our-work/later-life/communities-of-interest/care-homes-liaision-/hartlepool-care-home-liaison/

Image source: Neo - The Matrix http://www.dailygalaxy.com/my_weblog/psychology/

The Communication Initiative Network and holistic bandwidth

In 2004 I attended a day at a community informatics conference in Brighton, UK (see the side bar for details). My interest in that event stems from recognising the different schools of informatics and the multidisciplinary potential for Hodges' model that extends beyond health and social care. The model provides a cognitive gymnasium for us to test and exercise our holistic bandwidth.

The notion of 'holistic bandwidth' really comes into its own within global development and communication. In 2004, or soon after I discovered The Communication Initiative Network. They kindly posted the Brighton position paper on their site and were very encouraging regards the model. Now they are developing a new Communication Initiative Social Networking Platform - http://groups.comminit.com/

There are many groups including:

• The Future of ICTs and Development
• Communication and Climate Change Adaptation

In the above group I learned of the following initiative :

There is an interesting initiative in Africa called AfricaAdapt. It is a network that works to facilitate the flow of climate change adaptation knowledge for sustainable livelihoods between researchers, policy makers, civil society organisations, and communities who are vulnerable to climate variability and change across Africa. There is a whole section on their website that allows for communities to upload their own information on how they are adapting to climate change. The initiative also offers an award for best community project which helps elicit contributions. See http://www.africa-adapt.net/AA/

Africa: never far from the news. Lets hope this next week there is some +ve news from COP15 Copenhagen.

• Students - Communication for Development
• HIV/AIDS Strategy: Future Directions
• Polio Communication Consultation Group

There are diseases lost to the developed nations and with diseases like polio and leprosy communication and education are central to those who are ill and their families. Even as a nurse there is a stark reminder in the need for an International Leprosy Day.

• Gender, Education, and HIV/AIDS

On the teaching psychology list someone asked this past week about alternatives to structure a student's lifespan assignment. I suggested Hodges' model an approach that can also be adapted to educate people about disease ....

SCIENCES: aetiology, prevention, transmission, hygiene, diagnosis, prognosis, evidence, research, physical resources, drugs, nutrition, age, weight...
INTRAPERSONAL: attitudes, beliefs, education, literacy, personal responsibility, mood...
SOCIOLOGY: social networks, cultural beliefs, gender expectations, community, family, friends, trust...
POLITICAL: policy, leadership, funding, activism, infrastructure: housing heating..., access to services, media, employment, governance...

• Ethics in Communication for Development
• Gathering Theories and Models

This group only has 5 members and is of obvious interest to me. I can't recall whether I signed up: must check! Planning and development in this context covers topics and issues I know nothing of and yet I am sure that dressed in its socio-technical guise Hodges' model can contribute to the theoretical development here. It could be that there are other perspectives, models and conceptual frameworks to be found that can inform the global health agenda?

• DRAFT: Technical Update on Social Change Communication and HIV/AIDS
• Human Rights and Technology
• Web Site Directors

So, do visit the Communication Initiative both the new groups above and the general website.

Drupalcon Paris 2009 "big picture..." x 5 "holistic..." x 6

Today at Drupalcon my keyword count by the speakers of day 3 sessions I was privy to (assuming I was awake throughout) is something like:

"big picture" = 5
"holistic (+ or - thinking)" = 6

These were stressed repeatedly especially by keynote speaker Chris Heuer. Like last year in Hungary I have looked at the BOF (birds of a feather) board and wondered about sticking Hodges 'framework' up there. Why 'framework' and not 'model'? Well framework, product and service are amongst the other keywords at Drupalcons past, present and future no doubt.

Hodges' model is a framework to carry, represent and disseminate big pictures.

While it is very encouraging to me to hear these terms I get the impression this is window dressing. At the end of the day the 'big picture' is the paper around the fish and chips. Its value is quickly spent - especially in this most apparent recycled mode. Chris Heuer alluded to this in his very interesting talk.

There is more to see in the big picture than what seems to be there.


This is why Hodges' model is so readily passed over for its simplicity.

When we gather the constituent parts of the big picture they are invariably 'recycled materials'.

The converted can see the re-purposed value, the need to re-visit the frame and tinker with the contrast, horizon(s), sky and colour; but critically do those who really need to create, see and utilise the resource?

The thing about 'big pictures' is
they are not enough in themselves,
it depends not only on how you fold them,
but on how hard you can throw them.

Image sources:

Fish and chips in paper: http://www.roadfood.com/Restaurants/SearchResults.aspx?st=photos&ob=RestaurantName&ps=1&s=XX
Paper plane: http://www.clker.com/clipart-4601.html

Workshop - Delivering High Quality Health Care for All: Bringing the social and technical together...

My SOURCE: SOCIOTECH at JISCMAIL.AC.UK

Dear Colleague,

Please find details attached of a Think Tank focused on developing socio-technical approaches to the provision of healthcare (in the context of the National Programme for IT in the NHS).
Please note that attendance is restricted to around 30 people and that anyone wishing to contribute will need to apply (as specified in the attachment) - which follows below PJ.

Thanks and best wishes

Chris
P.S. please feel free to circulate these details to colleagues who you think may be interested. Thank you.

Professor Chris W Clegg
Centre for Socio-Technical Systems Design
Leeds University Business School
University of Leeds
Leeds
LS2 9JT
c.w.clegg at leeds.ac.uk

Delivering High Quality Health Care for All:
Bringing the social and technical together for a joined-up approach to deliver supporting systems and technologies
10th/11th December 2009

Call for contributions to an event organised by the UK Faculty of Health Informatics and the BCS Socio-Technical Group

Core idea
This 2-day Think-Tank event has been set up to discuss and report on how Health and Social Care employers and other key stakeholders in the Informatics field might bring about a joined-up approach to the implementation of electronic health records, one that brings together changes both in technology and in the social practices around it.

Rationale
The National Audit Office’s report on “Delivering successful IT-enabled business change” see: www.nao.org.uk/publications/nao_reports/06-07/060733es.pdf and the University College London Evaluation report on the Early Adopters of the Summary Care Records project (see: http://www.ucl.ac.uk/openlearning/documents/scrie2008.pdf) both highlight the challenges of implementing technology-based projects within a fixed time line and how this can reduce the opportunities to get a more “user-centred” approach to change.

In many sectors of the UK economy the drive to get the technology ‘on desk, on time, and on budget’ can mitigate against developing a full understanding and consideration of how the changes may be of real practical value to users and customers.

It is increasingly recognised that ‘technology-push’ will not be enough in its own right to achieve the full benefits and efficiencies that are being sought in service delivery. Rather, we need to bring about innovations both in the technical systems, and in the working practices, work roles and processes that surround them. Put bluntly we need a more joined-up approach to change. This has been variously called ‘user-centred’ or ‘socio-technical’ or ‘holistic’.

Objectives
The objectives of this event are to discuss and subsequently report on –
• What does such a joined-up approach mean in practice?
• What examples exist from across the UK Health and Social care sector where such approaches have been used?
• Who has to do what, to make it happen consistently across the NHS and Social Care services?
• How will we know if it is succeeding?

Organisers
The event has been organised by the UK Faculty of Health Informatics and the BCS Socio-Technical Group.

The event will be chaired jointly by Professor Chris Clegg, Chair of the British Computer Society’s Socio-Technical Group the and Doctor Beverley Ellis, Joint Vice-Chair of the UK Faculty of Health Informatics.

Getting involved as a contributor or delegate at the event
If you wish to attend the Think Tank, please submit an Expression of Interest (EOI) to Bruce Elliott, Co-ordinator of the UK Faculty of Health Informatics at bruceelliott@nhs.net by 28th September 2009.

Your EOI should include brief summary (of up to 200 words) of your role, experience and expertise in this context.

Please note we are seeking people from a range of stakeholder groups including:

• Acute Hospitals
• Suppliers
• Health and Care Commissioning organisations
• Primary and Community Care Providers
• End users of nationally-led systems, e.g., CMS, SCR, ECR
• Connecting for Health, Informing Healthcare and the Scottish Government’s E-Health Programme
• Academics
• Patient Leads

In the event that we are over-subscribed, we will select people so as to provide an appropriate balance of experience and expertise, to ensure the Think Tank can meet its objectives.

Please make it clear in your EOI if you would also like to present a short paper at the event. In such a case please also add a brief abstract of your proposed paper (of up to 200 words).

If you have been allocated a place you will receive written confirmation along with a copy of the final programme by 16th October 2009.

Associated papers
In November 2009, a Position paper capturing some of the Key Challenges in adopting Socio-Technical approaches will be shared with the participants to identify some of the key issues that will be addressed at the event.

Following the event, up to 5 contributors to the event will be commissioned to write papers on the topics and issues emerging, with the aim of informing key stakeholders in how Socio-Technical approaches can be utilised effectively across the NHS and Social Care. These papers will be completed by the end of January 2010, for inclusion in an overall Briefing report. We will also be actively exploring avenues for wider publication in order that the good ideas can be spread and acted on.

Location
Weetwood Hotel and Conference Centre, Leeds

Holistic care and 'where' it means....

Delivering holistic care does not mean being -

here	here
here	- or here

Holistic care is not even
about being in all these
places at the same time.

It means you have already
been to these places and you
will be going back again.

Holistic care also means
none of the participants travel alone ...

Complex signatures

A signature is a very personal thing and has been since writing, power and authority were formalised in pre-printing times. Today with identity theft rampant, effective means of assuring, legitimating and protecting 'signatures' of various forms is a pressing concern.

Signatures matter in health and social care and not just because of individual budgets, but there again....



If an individual is suddenly vested with a budget for personalised care, then what about our expectations of them? What are the expectations of the councils counting pennies length and breadth of the land? The creative use of budgets depends upon self-knowledge, or reliance of the knowledge and experience of others. If things are to change - this requires in the first instance, personal reflection and insight that instils the confidence to take risks, a critical degree of self awareness with a piquant of realism. In the second instance an internet portal, other resources, perhaps a person is needed gifted (indeed) with holistic oversight and awareness of the individual's 4-5 fold unique care signature and local care economy.

Signatures are not new in health care. An effective relapse signature is a difficult and personally costly resource to identify, implement and refine. And yet this invaluable currency facilitates self-care management for many people with mental health problems and long term medical conditions.

Just as our written signatures change as we age, people had better get creative to ensure individuals are equipped and can be equipped with a care signature of their own.

Yours Truly,

Defining e-Health

E-Health is a compound and dynamic term for people, health (and social) care education and delivery, organisations, information and communications technologies (ICT), infrastructures, policies and means combined to facilitate, measure and improve the intentions, actions and outcomes of health (and social) care.

In a nursing context people refers to patients, carers, nurses and public; means refers to partnerships plus funding ranging from the macro level of the public sector to personal budgets; intentions, actions and outcomes covers education, the nursing process, records, quantitative and qualitative metrics.

To be holistic metrics must incorporate safety, access, personal outcomes, benefits, integrated informatics and economics.

1st draft: (c) Peter Jones

The moon, Saturn V, policy and holistic care

The last time human kind ventured to the moon it took a three-stage rocket to get us there.

Unlike the space race and Kennedy's breathtaking commitment, there never has been a political objective akin to - "We choose to achieve holistic care in this decade, and do the other things like multidisciplinary, integrated, electronically supported collaborative care. ..."

Perhaps the UK's series of National Service Frameworks goes some way towards this, with the Next Stage Review over the next decade set to make the holistic difference?

So, it appears that the objective of holistic care isn't easy, like going to the moon it is hard and in this problem domain - care engineering - we have had more than a decade to get there.

There has been a space race in nursing. A race to fill curricula, wards and the heads of many with models and theories of nursing.

Like Apollo this race has petered out.
Like Apollo this programme is safety critical.
Like Apollo ambition can be re-kindled.

We need a new imperative. Something to charge policy landscape of our time. There is still a need to deliver on this and the other things....

Hodges' model is a marvellous delivery system.

Unlike the Saturn V it boasts four stages.
Like the Saturn V it incorporates the means to take us to some place and make the journey back: quantity - quality and the universe between.

The stages of h2cm are interchangeable their use dictated by the situation and context. There is even recourse to a virtual fifth stage as required, since as the astronauts found:

you can find bliss up there : looking down here

Image source: ABC News

Ack: John F. Kennedy Moon Speech - Rice Stadium

Book chapter: Substance Misuse and Mental Health

With the chapter on socio-technical structures within Hodges' model due to appear very soon there is news of an exciting further project - a different publisher with a more purely clinical and social care focus.

Between now and 1 May I have accepted an invitation to produce a chapter addressing the holistic aspects of substance misuse and mental health. More to follow and a deadline to work to ....

1st Contact: ET and care on the front line

ET as in 'extraterrestrial' may seem remote from nursing and health care, but where there's a will....

Health and social care appears to become ever more specialised with each turn of the policy machine. People's lives are experienced as being ever more complex. Health care is filled with uncertainty and the public present with multi-diagnostic, person-centred, choice bearing, (usually) recovery directed problems, needs and strengths.

Pity then the care workers on the front line, at the point of 1st contact. Like the baseball catcher it helps if they can field the knowledge and skills required to cover physical, mental health and possibly learning disabled clients. You have to hope that coaches recognise that Hodges' model can help the team be aware and fully prepared to cope with 1st contact supporting and facilitating what follows. So, how does your team get to grips with complex care?

Additional links:

Baileff, A. (2004) Developing high quality first contact nursing in Southampton NHS Walk-in Centres. At, Innovations in Partnership, Practice and Education, 3rd Annual Scholarship Conference, Portsmouth UK, 2 Jul 2004. Southampton, UK, University of Southampton. http://eprints.soton.ac.uk/9197/

Declaration of Principles Concerning Activities Following the Detection of Extraterrestrial Intelligence http://www.setileague.org/general/protocol.htm

Image and source: Louisville Slugger OXFB Omaha Pro Series 13 Inch First Base Baseball Mitt from http://www.anacondasports.com/

Holistic Skills Assessment and Assurance

Just lately - by virtue of mailing list subscriptions - I've received several calls for research proposals and notice of workshops providing advice on how to proceed. In response let me just say this is 'frustrating' - as I'm not in a position to:

• (OK, on your marks! Get set! GO!) - formulate the real question;
• seek partners;
• put in a bid;
• and put conceptual frameworks for (global) health and social care on the map.

They deserve to be there. For me the really interesting note to take home here is that these potential research projects could be grounded in several disciplines:

• nursing;
• health economics;
• informatics;
• public health;
• public and civic engagement. ...

While universal in scope they (e.g. Hodges' model) are not the universal solution.

They can and must complement other tools and resources as the care agenda shifts to quality and the measure of quality.

More than ever the holistic reach of not only 1st-line but 2nd-line ... staff is going to be crucial to how well policy-bearing organisations carry their load.

As the (quickly formulated, rapidly fixed) physical and emotional bandages are renewed and re-assurances given, we realise that (ill-) health is not just a condition specific conundrum. Health is a melange of choices, multiple diagnoses, beliefs, attitudes, educational opportunities, concentrated resources and much more that are difficult to focus. Strange thing this notion of inclusion. At the end of the day it comes down to:

The art of focusing without focusing ... ?

Holistic bandwidth means that that the holistic skills demonstrated at any time will be dynamic and vary according to the viewer, the context (and there will be several), the care domain and of course the measure(s). ...

Additional links:
Measuring of health and health-related quality of life with the EuroQol-5D

Image c/o - Wordle - and based on this blog.

The Public, Patients and Carers in Hodges' model

The table below indicates some of the main concepts and concerns that
surround the PUBLIC, PATIENTS and CARERS agenda presented using the four care domains of Hodges' model:

INTERPERSONAL : SCIENCES
SOCIOLOGY : POLITICAL

Well-being, mental (subjective) health, mood, hope, human spirit. Knowledge and understanding of condition. Literacies: 3Rs, ICT, social, visual, spiritual, health.... Diagnosis - prognosis. Psychological impact. Aware of info sources tolerance, personal choices & autonomy. Response to trauma, threat, loss. Belief systems. Coping strategies. Emotional memory Perception. 'Individual pain' Motivation. Responsibility Ability to work, disability, gender Individual engagement, personhood, dignity. Self-care, Purpose Personal Health Record Attitudes, beliefs

Physical (objective) health. Chronological - Pathological Age (of care subject, carers). 'Fitness'. Activity. Systems. SAFETY PROCESSES, structural flexibility. Pain thresholds. Measures (Pain genetics, scorecards). Systems, feedback, redesign, improvement. Complexity. Change. Research: Evidence-based care. NICE. Quantitative, Quality of Life, assessment, screening. Process redundancy. Decision making PEPIN: Professional Education Public Involvement UK Network Referral, care pathways, plans, time. Self-admin drugs. Expert patient. Health, care, eng. model(s) Ill-health - Health promotion Time for data collection. Curricula design, Courses, qualification. Standards vs Innovation Computer supported engagement*

Carer - family understanding of condition, diagnosis-prognosis. Genetic implications (if any). Familial genetics pain. Sense making. Meaning. Social articulation of individual +ve & -ve experiences. Generational (role) inversion. Engagement and Social inclusion: work, social mobility, homelessness, stigma, poverty. Access to info and comms technology The Engaged E-patient Population Medical Sociology. Sick-role. PRACTICE Effects of culture 'meanings'. Dependency. Religion, fatalism. Leisure. Volunteering. Social capital / capacity. Collaborative care, concordance. Socio-cultural reach. Communications. Media. Dialogue. Qualitiative research. Social change attitudes. Shared definitions and meanings: 'engagement', 'health', 'wellness'...

POLICY, Nat. - U.N., FUNDING, GLOBAL ECONOMICS. Legislation: Section 11 of the Health and Social Care Act 2001. Nat. programs: Health For All. Health & Local Social Service Auths, 3rd & Independent sectors. Choice, Equity, Equality, Access, Advocacy Services. Consultation, engagement. (PALs) LINks. Definitions: engagement continua, datasets, intelligence / reporting. Service planning and development. 'Localisation' - Center. NHS Constitution Scalability of concept: Grp - Ind. Organisational empathy ('x.org' <-> public, patient 'rapport, involvement'). Economic cost of prolonged 'patiency'. 'Patient Lead'. Compliance. Political priorities, strategy, continuity. Policy half-life. Consolidation. Governance. Expenses. Specificity of roles, social exclusion. Wellness. Disability. Human Rights. Invalidity. Re-training. Health outcomes, assessment. (Lay) Representation. Champions. Black, Minority, Ethinic groups. 'Citizen-Patient'? DoH INVOLVE1 Involve2 Retirees. NHS: 'Open All Hours' Dedicated centres: e.g., NCI3

The focus above is UK, but can be readily revised to reflect other countries.

1. INVOLVE: Promoting public involvement in NHS, public health and social care research.
2. Involve: Promoting public and patient involvement in policy making and service design.
3. NHS Centre for Involvement.

Additional links:

Patients' use of the Internet for health related matters: a study of Internet usage in 2000 and 2006
Healthy Democracy: The future of involvement in health and social care, Edward Andersson, Jonathan Tritter and Richard Wilson (Editors).
Dept. of Health, Patient and Public Involvement
Engage, Northern Ireland.
The Local Government and Public Involvement in Health Act 2007
LINks: individuals and community groups who work together to improve local services.
Our health, our care, our say: a new direction for community services.
Patient Information Advisory Group (PIAG).
National Patient Safety Agency

The SOCIOLOGICAL links page includes 'Seven Ages', 'Public, Patients, & Carers'...
The INTRAPERSONAL links page includes 'Mental Health', 'Psychology', 'Therapies'...
The POLITICAL links page includes 'Policy', 'Citizenry'...

*Several informatics schools: community, urban, social, health, nursing, gender, e-gov...