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...?

Notes (ii) from Paipa Conference: Q & A

Q. What is the appeal and relevance of Michel Serres to the Health Care Domains Model [h2cm]?
c/o Fred Manrique / UPTC 

(As per the paper - Exploring Serres’ Atlas, Hodges’ Knowledge Domains and the Fusion of Informatics and Cultural Horizons. 2008)

A. I cannot remember how I came across this French philosopher (Bruno Latour?), but in 2004 I started to read some of his translated texts. Serres' work is not easy to read, but rewards perseverance. Thus enthused I wrote (in my spare time) and eventually submitted a paper to a prestigious nursing journal. This was rejected - twice. Using the feedback I was able to produce the paper that found publication in the informatics field. This is listed in the W2tQ bibliography. Serres' ideas were remarkable in how they spoke to me and reflected in many ways the conceptual framework of h2cm. I need to revisit Serres, but ideas of particular appeal include his use of several tropes:

• Harlequin: the uninvited guest (disease, illness?), mischief (health taken-for-grantedness), chaos (the unpredictable);
• blanc: in my presentation I included a blank slide. There it represents every new person, new page - no judgements, positive regard. A page for lifelong learners and being able to self-reflect.
• Hermes: the Greek God, the messenger - information and Serres' early study of information science. The 'underworld' - nursing and medicine - are not for everyone. The importance of ports as a means of information and cultural exchange - today economies see themselves as information ports and the rise of information portals.
• Serres states (as do other commentators) that the Internet will provide opportunities for new scholars, outside of established academic institutions.
• borders, boundaries - the middle: in life we often have to ask do we continue and cross the middle?
• The Planet: Serres is concerned for how we treat the planet. The health care domains can also be utilised to explore the physical and psychological impacts of climate change and the need to attend to human ecology. We are rocking the boat - Earth is our boat.
• ... plus many others - fluid, dynamics, life - rivers - choices, narratives, Home, Angels, statues.

Finally, within "... S E R R E S ..." you will also find H2CM!  

Please see the bibliography for the paper and contact me for a copy if you wish.

Additional links:
Serres on this blog.
http://michelserres.blogspot.com/

More Q and A to follow plus photos and slides. Photo source (PJ, Copenhagen shop window, 2010)

Notes (i) from Paipa Conference: Q & A and sessions

Questions from the delegates (once more interpreted by Andrea Ramirez) at the plenary session on Friday 25th February included  - with my response (extended here):

Q. Could you please give some specific examples of the model's application and its achievements?

A. The model was created by Brian Hodges to facilitate reflective practice and encourage holistic care - especially balancing physical and mental health - psychological - care. In the mid-1980s the model was used in several locations in England and the Isle of Man. The model was taught and learning assessed through case studies in community mental health nursing, learning disability and health visiting.

As highlighted in the presentation unlike other models of care h2cm has not had the benefit of specific research. The models of care we use must be evidenced based. The website and blog represent a call for research in the health care domains model. This is why I appreciate so much this invitation to Colombia and being able to present what I believe is a very useful and increasingly relevant care resource.

In terms of achievement there are an as yet limited number of papers published and listed on the blog in a bibliography.

A couple of individuals have contacted me for advice on using the model in academic work, which has also been posted on the blog (see application).

In my presentation and the plenary I did not mention the planned workshop in the afternoon!

Q. What has been the experience of applying the model in the practice (clinical area) and in the community?

A. The model is used in two centers for forensic psychiatry (low and medium secure) where the inclusion of the interpersonal and political care domains are pivotal in the tensions between the custodial context and need for person-centred nursing care that arise.

In forensic nursing the model informs care philosophy and is also represented in care documentation. A paper is in production describing the model and this application.

The model is I understand being used in a research project investigating bullying within midwifery. I will post more details on this when I have them. The researchers approached me seeking permission to use the model, I indicated the model's origin - as in "It is not 'mine'", and furnished a letter indicating the model's status. I understand the appeal of the model in this instance may be in scoping the research project.

Currently the model is helping me in my role (as a Nursing Home Liaison Specialist) to plan and deliver education sessions to residential care staff on communicating with people who are coping with dementia.

Being simple in structure and basic content once learned the model is accessible as an aide memoire, while you are assessing, planning and evaluating.

I have also used the model when working on informatics projects, as the model can help integrate the SOCIAL and TECHNICAL aspects of ICT.

More Q and A to follow plus photos.

Presentation(s) at 1st Int. Congress of Nursing Models and Theories in Colombia

I will revise this post over the coming week and add more, including one of the Spanish slides.

Many thanks to Danny Eduardo Rodriguez for meeting me at the airport (and to everyone who waited  with Eduardo). Hearing my name and seeing the university transport proved instantly reassuring. Thanks also Eduardo for the in-session translation - a great help and for your efforts to ensure I felt at home and a part of things: I certainly did. ... 

Well I am due to leave Paipa soon for Bogota El Dorado airport and the trip home via Paris. It is a beautiful day in Paipa. Very warm, bright sun, from my room I can see people water skiing on the lake.


Yesterday's presentation, workshop and Q and A session were very well received through a lecture and workshop. These would not have been as successful with the brilliant work* of Interpreter Andrea Ramirez on both occasions.
I had started to add some Spanish translations to my slides and these were checked and extended by Luz Stella Saray and Prof. Wilson Canon Montanez, (UDeS) to whom I extend sincere thanks (a good photographer too!).


In the morning session Andrea related each slide in Spanish after my account. For the workshop I had emailed the case study in English with a Spanish version c/o Google translate. This had been checked and improved and the format we followed was for students to read the case study and then individually draw out the aspects of Alice's case (fictitious yet based on 20+ years of experience) which they feel significant across the care domains. During this exercise for 20-25 minutes Andrea assisted again with some questions from individual students. Then in groups of 4-5 they collectively reflected on their 'results'. Finally each group in turn offered one item for each of the four domains. Astute questions from the floor and discussions followed. Not having done this before, with the addition of translation I was surprised at how well it worked: instant teamwork!

At 5.30 Luz had arranged to meet to discuss nursing in England. A little jet-lagged, I thought she meant with 2-3 colleagues, but in the end the room was filled as we were joined by 60-70 students in a circle. I can't believe that 90 minutes passed. The students and faculty are so very enthusiastic, charming, friendly and knowledgeable. Two days is not long to learn and make judgements, but from the student's questions they seem acutely aware of the specific health challenges and issues they face in Colombia. Their professor's approach in pursuing this meeting reflected an awareness of 'nursing as it is learned and practiced elsewhere'. I advised I was not able to speak generally, outlining my specific role and location. I let them know I was drawing from matters I do know (as highlighted on W2tQ) and personal experience. The notion of 'basic nursing care' is clearly and unsurprisingly universal given this encounter.

You do need to consider such travel very carefully: your health, security, travelling alone... The organisers took care of this assuring a personal meeting at the airport, transport and accommodation. The journey was hard for me from the UK. A short hop Manchester to Paris 1.15-30 was followed by an 11 hr and 10 hr flight back home passing through Bogota. Travel is difficult due to the condition of the roads, driving laws and the traffic situation that the populous of Bogota faces; but where there are 'gaps' (pot holes!) there is a way through.

I never would have believed I would set foot in South America. To stand under Orion and see Canopus was another dream come true. As Space Shuttle Discovery set off on her last flight I was making discoveries of my own in helping others do the same.

I am very grateful to GICS - the three Universities UPTC, UdeS and Unillanos who invited me and supported my attendance; plus my employer Lancashire Care NHS Foundation Trust and colleagues covering duty for new referrals at the Beechurst Unit, Chorley, Lancashire. This has been a marvellous experience, with many contacts made that I hope will grow in the future.

*Presenting in Spanish at the conference (Teoría “Marco de la Organización Sistémica” con enfoque en Familia), Dr Marie Luise Friedemann - RN, PHD and her husband informed me of Andrea's effectiveness and memory feat. Dr Friedemann, Profesora de la Universidad Internacional de la Florida, in Miami and I also hope to compare our respective interests.

Reflections on publicising The 1st Int. Congress of Nursing Models and Theories in Colombia

Inevitably I have posted news of this conference and presentation to several mail lists. I received a reply pointing out that this news was short notice and getting to Colombia in the time remaining would be quite a feat. I replied saying that I had only just sorted medications and my yellow fever jab was only just 'active'.

I realise you can read all sorts into such short notice, but apart from being truly flattered and cock-a-hoop about this invitation my post was intended to raise a question...

In October 2009 I posted a fictional quote apparently cited from a conference in 2015 by:

Ms. Florence Seacole Mashaba*. 3rd Year Student Nurse
Keynote address 2nd February 1000hrs
Global Conceptual Frameworks for Health & Education:
1st International Conference on Visualization in Care Models, Assessment and Evaluation.
St Francis Bay, South Africa. Monday 2nd - Thursday 5th, February, 2015.

Future Conceptual Frameworks for Global Health: a quote

Nursing models and theories are still a feature on nurse curricula. As a mentor I check when student nurses are on placement with us - the community mental health team. What models have they come across? What are their thoughts about them? Many models of nursing still have an active following and conferences. The oomph factor is definitely lacking though. As a feature models and theories are but a frame or two in a busy learning schedule. Where does informatics figure? Does geography begin and end in school or maybe the hospital site map? ...

Then here, suddenly in Colombia is the 1st International Congress. I do hope this is the first of several and an awakening. An awakening not of a fashion item (perish the thought), but an emergent attentiveness to theory that is mature and ongoing. A thread that is worthy of the communities and populations we serve, the students we must inspire to one day be leaders themselves, the disciplines with whom we form 'the team', the people - patients and carers - we must also educate and empower.

We need models (yes plural) of care that extend beyond nursing across the four care domains and several divides. That is where the pearls of enlightenment lie.

<->

I opted for St Francis Bay as the 2015 venue recalling the film The Endless Summer. This will be the closest I have ever been to the equator.

* Personal communication from a future fictitious individual. ;-)

1st Int. Congress of Nursing Models and Theories: Colombia 24th-25th Feb. 2011

I am delighted to report the news that the

Health Care Domains Model

will feature at this International conference.

In November I received an invitation to be one of the main speakers from the Grupo Gics Investigacion Team; and so next month I will be heading south to Paipa, Boyacá, Colombia.

This prospect would not be possible without the support of the conference organisers - GICS and Prof. Wilson Canon Montanez, Nursing Faculty of the University of Santander UDES (Bucaramanga-Colombia) and my employer Lancashire Care NHS Foundation Trust.

Recently a group of Nursing Faculties of three major Universities in Colombia (Universidad de Santander UDES, Universidad Pedagogica y Tecnologica de Colombia UPTC y Universidad de los Llanos UNILLANOS) have come together to organize the First International Congress of Nursing Models and Theories.

This congress will be held in the city of Paipa-Colombia 24 and 25 of February, 2011:
http://www.uptc.edu.co/eventos/cong_enfermeria/index.html

I very much look forward to this trip for several reasons:

• New people to meet and things to learn.
• This invitation literally puts h2cm on the map (so I must deliver)!
• It is marvellous to see faculty and nurses in Colombia re-invigorating thought about models of nursing.
• I have never travelled this far south - how will Orion look?

This will be a great adventure, but before then - where's my checklist: presentation(s), jab, tabs, passport...

Nursing: magnetic Force 5

Back in 2009 I came across a post - Nurse magnets crucial for recruitment and retention about the 14 Forces of Magnetism:

In 1983, the American Academy of Nursing conducted a survey of 163 hospitals to learn why some hospitals attracted and retained well-qualified nurses who were devoted to quality patient care.

The 14 Forces are listed and described by the ANCC. The forces themselves include:

• Force 1 Quality of Nursing Leadership
• Force 2 Organizational Structure
• Force 3 Management Style
• Force 4 Personnel Policies and Programs
• Force 5 Professional Models of Care
• Force 6 Quality of Care
• Force 7 Quality Improvement
• Force 8 Consultation and Resources
• Force 9 Autonomy
• Force 10 Community and the Hospital
• Force 11 Nurses as Teachers
• Force 12 Image of Nursing
• Force 13 Interdisciplinary Relationships
• Force 14 Professional Development

The professional, organizational, and political (policy) emphasis of the 14 forces is obvious and becomes clear when each is weighed in terms of where it sits within the domains of h2cm.

Try it as an exercise. ...

Recruitment is ALL about magnetism.

If you are unsure, ask a magnet about the meaning of retention.

Demographics are already applying pressure upon these forces of magnetism. Not just when referred to explicitly in the USA within organizational media; but globally. Demographics is another magnet - it approaches with increasing force.

From here in the UK (and readers elsewhere) we have to exercise care when models are mentioned. While the theorists and philosopher's of nursing nail their definitions to the mast (h2cm?) there remains a models muddle, not just in the variety of models of care, but in the levels at which they operate. This is not a criticism, it's an observation - consider Force 5:

Force 5: Professional Models of Care
There are models of care that give nurses the responsibility and authority for the provision of direct patient care. Nurses are accountable for their own practice as well as the coordination of care. The models of care (i.e., primary nursing, case management, family-centered, district, and holistic) provide for the continuity of care across the continuum. The models take into consideration patients’ unique needs and provide skilled nurses and adequate resources to accomplish desired outcomes.

In the US in particular 'models of care' (moc) often refer to finance and accountability of costs (the market process), in the UK moc might refer to commissioning. In Force 5 the addition of 'Professional' (as the original author's no doubt recognized) is crucial. If you repeat the above exercise, plotting Force 5 on the Health Care Domains Model then you see how Force 5 works for nursing and remains to this day a great achievement as a yardstick for quality, assurance and retentive power.

In the almost 30 years since the research on the 14 Forces, I do wonder though if there is a need to imbue the following with magnetic properties:

• person-centred care;
• self-care;
• carers and public engagement;
• prevention;
• public (mental) health
• and informatics?

Yes, many of the above can be assumed to lie within the existing Forces 1-14. Health and social care are not static. Nursing has much to contend with from the level of the individual practitioner through to the group within an organization. The 14 Forces of Magnetism are well established in the USA and deservedly so, they clearly deliver.

In the political and economical heat of an economic recession, however; magnets may reach their particular^* Curie point. Then they cease to work.

The constant bangs and knocks of change, the incessant hammering of party politics and the 'market' on the door of "high quality nursing care" can also take its toll on magnetism.

Nursing needs to take care.

Related post on Healthcare IT News:

Top 10 trends for 2011 include IT, new care models

*OK it should be constant, but like our patients these magnets are not all the same - they have varying levels of vulnerability.

To follow some definitions from an olde book ...

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!

Musings... axes in hand and mind

...

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

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

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

(Which begs me to ask myself:

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

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

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

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

....

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

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

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

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

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

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

Axes in hand and mind
...
PJ Dec 2010

Buller and Butterworth: Skilled nursing practice - four domains?

The health care domains model identifies four domains within health and social care and medicine. What evidence is there to support the model's inclusion of:

INTERPERSONAL : SCIENCES

SOCIOLOGY : POLITICAL

- plus the spiritual within and without? Steve Buller and Tony Butterworth undertook a ethnographic study in 2001 'Skilled nursing practice - a qualitative study of the elements of nursing'. With skilled nursing practice at the center (Fig. 5.) they identified:

relating and communicating	doing the job
being professional	managing and facilitating

There is some overlap, reflection arises in relating and communicating and doing the job. Overall however there is a definite correspondence between these domains and those within h2cm - the health care domains conceptual framework. I have equated being professional with the SOCIOLOGY domain as for the authors this includes being with patients, conveying confidence, handling situations, being informed. Managing and facilitating is undoubtedly POLITICAL with supervising, auditing, making sure things get done. Doing the job - is based upon planning, informing, assessing, intervening, and being confident (with equipment, procedures, manual dexterity..?).

Having been thinking and writing about h2cm for many years it is a shame that other models have benefitted from funding and gain "ward and community (research) cred" while here evidence is retrofitted. Looking at the paper just in the decade since submission and publication I wonder which elements remain local, and where other elements of the skills base (care concepts) have migrated to ethnographically?

Steve Buller, Tony Butterworth (2001) Skilled nursing practice — a qualitative study of the elements of nursing. Int. J. of Nursing Studies. 38, 4, 405-417.

Comets, holistic care and peripheral vision

Comet Hartley 2 is still bright and yet throughout its visit by Earth quite diffuse, so I have yet to try to find it with my binoculars. To effectively use binoculars, a telescope (or even a microscope) and enjoy the astronomical delights (especially as Councils save money and switch off street lights) it helps to develop your peripheral vision.

Nursing, medicine and social care calls for its own kind of peripheral vision. Peripheral vision that nonetheless enables us to really see. It is ironic that in order to see the big picture that includes the person, that allows us to coherently assess, plan, deliver and evaluate person-centred care we must look off-center.



Comet image source: http://maineastro.com/2010/10/binocular-comet-now-high-in-the-sky/

Fran Biley's video: Students on nursing theory

I came across this great video created by Francis Biley Bournemouth University through the Martha Rogers list:

Quite some time ago I wondered about having dummy - animated heads to carry out a dialogue. It is great to see how e-media forms and tools have developed now.

I have my own thoughts and ideas on nursing, perhaps over time I am drafting them in the bibliography and here on W2tQ?

Additional links:

Nursing theory resources SCIENCES links

Virtual Reality in Nursing: A dialogue from 1991

Nursing Telemachus and Computers: A dialogue from 1995

Care origin(s) and open access #OAW2010

The most striking and ubiquitous presence in the health career model is its basic diagrammatic form. The image at left provides some mathematical additions and there at the center is the origin.

In this respect the model (literally) draws our attention to the identification of the care problems, constraints, strengths, solutions that affect the individual with whom we are engaged. We are immediately aware that there is inevitably more than one aspect to consider.

To save repetition I am only going to refer to problems. So, the model's form highlights that there is no single origin of problems, but many. At some time a problem, for example physical, may become the priority. Then the SCIENCES domain is critical. Deprivation of liberty concerns may split the priority creating tension across the INTER-intraPERSONAL and POLITICAL domains.

As priorities are dealt with there needs to be a return to the -

origin.

The question is asked: in which care domains do the problems lie? We call this re-assessment and evaluation.

In Open Access Week the health care model is also 'open access'. Not just in terms of being a free, accessible resource available to all, but being discipline agnostic, neutral and applicable across cultures and ethnic groups. The model is also open in terms of mindset. The users of h2cm provide that and as they do open* and origin-al care unique to the individual has a chance to follow.

*Open care? Mmm...


Image source: origin - http://en.wikipedia.org/wiki/File:Coordinate_with_Origin.svg

New to nursing? after Jules (just scratchin the skin)

If you are new to nursing (social care, learning disability, forensic nursing... ) we have some amazing guests on this weeks show, appearing especially for you, because of you: because you care - on four stages ....
[with apologies: Jules Holland, BBC 2]

Interpersonal : Sciences

Sociology : Political

Self Awareness orientation communication rapport, empathy anxiety values, beliefs mood, risk knowledge & skills aptitude and attitude	anatomy and physiology (The) Make the Beds  TPR [BP] hygiene birth...........................................death drugs journals, books nutrition assess, plan, actions, evaluate tech & equipment
community family relationships culture traditional medicine social networks public involvement	HUMAN RIGHTS Consent, Choice, Capacity health economics Law DoH, NLM, WHO health social care services professionalism policy

Balanced Care: Safe Landings and Recovery

In health and social care patient, family and the health care team are united in what is constantly described as a journey. Sometimes there are several, care pathways into territories unknown.

Unknown?

Well yes, if care delivery is personalised (who are we to assume ...?); and yes again even if the patient - the individual concerned is an 'expert' in their condition.

Apart from the metaphysics of life's journey our physical environment can present dangers and yet fewer and fewer corners are truly  unknown. We leave it to astronauts (and oceanographers) to adventure on our behalf. Prior to the Apollo missions it was essential to confirm the nature, solidity of the lunar surface. Would a spacecraft sink and possibly tilt to the extent that return to lunar orbit and Home was impossible?

The Apollo Lunar Module's four legs provided support for a safe landing and take off. A base in every sense.

In health and social care the health career model can provide a base and re-assurance too. Each of the four care domains allied with knowledge and skills - holistic competence - can bring about a successful mission: however the crew and 'success' are defined.

Image source and original text below from:
http://www.robertaonthearts.com/id763.html
Cartier Replica of a Lunar Module
Three individual 18-karat-gold models of the American lunar module were made in 1969 by the jeweler Cartier of Paris on behalf of the French newspaper Le Figaro and presented to the three Apollo 11 astronauts during their post-flight tour in Paris. This model was presented to astronaut Michael Collins.
Image ©Nick Welsh/Cartier Collection 2006

The art and science of Serresian spin

To Michel Serres:
- the middle is a point of reflection, a point at which questions - the question - must be asked. In fulfilling the purposes of the health career model:

• bridging the theory - practice gap;
• facilitating holistic practice;
• supporting (personal and group) reflection;
• enabling curriculum development;

- the model's four domains are constantly (re-)visited in turn. Motion is constant. Conception - birth provides that initial impetus. Health status. Life - momentum. Centered on the person the movement is usually self-correcting, seeking balance. Health care. Questions and answers whether whole or in part follow, leaving a trail of care delivered and care planned. A record.

There is definite synergy between our use of the health career model, the dynamic quality and quantity of health and social care and Serres' description of the spinning top:

"The behaviour of the cone or the top is worth analysing. Throw this toy and describe, as Plato did, what happens. It is in movement, this is certain, yet it is stable. It even rests on its point or its pole, the more so as its movement is rapid. All children know this. But its rest is still more paradoxical. The top may move about, by translation, without ever losing its stability. To repeat, it can do so as long as it turns very quickly.


Even better, its axis may lean, take on an inclination, without putting the movement of the whole in too much danger. It may again rock, by nutation, oscillating around a mean location. This very ancient and quite childish machine is marvellously instructive.

First of all, it combines and the movements known and thinkable at the time: rotation, translation, fall, leaning and swaying. An integral model, additive, overcharged, yet simple. Second, and above all, it conjoins in a simple one-off experiment phenomena judged or presumed to be contradictory. It is in movement and rest, it turns and yet does not move, it rocks and is stable. The simplicity of a complexity, first and foremost, an additive machine; a synthesis of contradictions, beyond anything else. Now it may serve as a little model of the world, for a naive simple and local orrery. It quivers, at rest, it moves forward, turning, like the heavens, like the stars." p.28-29.

Michel Serres, (2000) The Birth of Physics, Return of the Model, Turba, turbo. Clinamen Press.


Image source: http://industry.bnet.com/technology/10002785/spinvox-or-someone-like-it-keeps-spinning/

earth, wind, fire, water AND the birth of physics

To begin - the health career model is concerned with space, structures and knowledge (care domains) built around two axes, plus the 'subjects' and 'activities' of health.

How we define and (so) divide space and accord that space salience amid changing contexts is critical to theory, practice and management and the models we subsequently derive:

... The dichotomy does not cut, it defines, it surrounds the closure of a limit, it delineates a boundary. Within the space thus enclosed like meets like. Or rather, conversely, the specific convergance [convenance] or identity, the assembly of the analogous, delimits zones in the disorder which are distinguished from each other. The earth is separated from the waters, air divides from fire. ... p.28.

Michel Serres, (2000) The Birth of Physics, Return of the Model, Turba, turbo. Clinamen Press.

water	earth
air	fire

Carer's support evidence / measures and end of life care

The following e-mail was received this week from (Prof.) George Kernohan and includes correspondence with Mary A. Waldron, Research Assistant, University of Ulster (thanks to Mary for confirming the reference).

My responses to George's points are right justified, italicised.

<->

Peter,

I am beginning to find examples of Hodges’ model every day now.

Once you adopt the model as a framework George it does tend to frame everything,
so I am not surprised at your finding. Maybe there is a paper there too...

Today we had a second research meeting to consider a (more) rigorous attempt to evaluate the provision of ‘support’ to carers of people undergoing palliative or End-of-Life Care (EOLC). An area of care with a dearth of evidence. So we looked at one review from Grande et al. (2009). They say that:

There has already been considerable research identifying carers’ needs in EOLC. These include psychological support, information, help with personal, nursing and medical care of the patient, out of hours and night support, respite, domestic and financial help.^9,10,16–21 There is also a large body of research into adverse effects of care-giving, such as anxiety, depression, stress, strain, fatigue and mortality.^22–24
Given this strong evidence base, any further investigation into the prevalence of needs and adverse effects should mainly focus on under-researched groups to ensure that future interventions are sensitive to their specific concerns. This includes carers of patients with conditions other than cancer, including neurodegenerative disorders,²⁵ respiratory²⁶ and cardiovascular diseases,²⁷ to help us understand how differences in disease trajectories, awareness of the terminal nature of the disease and available support²⁸ translate into different carer experiences. Although carers of patients with dementia have been extensively researched, little is known about their needs during patients’ final phase of life.⁹ p.340.

(The numbers refer to references by Grande et al., I have extended the quote used here).

Thanks for this paper George (and Mary) which I will read in full.
I extended your quote to encompass some additional interesting ideas.

To move toward a plan for a more rigorous evaluation, I would like to use a simple framework: here we go!

I think I will be suggesting Hodges’ Health Career as a possible model.

:-) ! If I can support you in this George I am pleased to help.

This could provide a framework for all carer-focused interventions in a broad way. As always, it would imply that carers need to have their needs addressed in terms of science, sociology, politics and interpersonal needs. As I see it, the first step would be to ‘map’ the carers’ needs onto that framework (from publications, if necessary from carers themselves). The basic idea (I think) is that care should address the four quadrants:

• Science: (carer’s physical needs, information, instruction)
• Political: (policy that enables care for carer, finance, allowance)
• Sociology: (recognising that people need people, networks and “sharing” groups, story telling/hearing)
• Interpersonal: (psychological support, prevention of anxiety & depression)

Have you any thoughts or guidance on this “mapping exercise”?

Goodness, that's quite a question!

Plenty of thoughts George but not sure how meaningful ....
Basically, since a community mental health project in 1990s
I have always considered (as per standard approach of course) that a toolkit of measures are needed. Even when we start from that most basic of distinctions between demand and supply.

As per your approach if h2cm is considered as a circle, a spectrum -
(sometimes we must circle the square)
then (if holstic) the adopted measures should cover all the domains:

Political: (outcomes, carer, patient satisfaction, financial assessment (means testing), respite care frequencies, reviews)
Interpersonal: (mood, coping ability, anxiety, depression, sleep, HoNOS)
Sciences: (pain, general health scales, care complexity (measures?))
Sociology: (dedicated carer assessment tools, sociability - social network size, psychosocial measures... there are many out there)

George, I realise the above is a ragbag collection but - like yours - these are dimensions which can (must) be reduced. Now there is also emphasis on this area post Darzi and the 'new' quality agenda.

This will serve (and is serving) to emphasize the distinctions between measures:

Objective - Subjective
Quantity - Quality
Staff administered - Self (Patient, Carer) administered
Global/general - condition specific
Service centered: Primary care - Secondary care

While it is easy to spin dichotomies,
the NHS must (constantly) focus on this area whatever the policy emphasis:

NHS Information Centre: Measuring for Quality Improvement

NHS Information Center: What is happening on indicators for...?

NHS Inst. for Innovation and Improvement: Quality and Service Improvement Tools

Earlier this year I contacted the NHS-IC [enquiries at ic.nhs.uk] regards additional measures of quality suggesting that the health career model bears due consideration (research).

Mental health services (and others?) have recognised how the measures they use can be a chaotic, personally selected, preferred, legacy-mix of assessment tools. Dictated by Senior Nurses, Consultants, Senior Management and not the evidence base. Now these are assured (are they?) with purposed selection (a task worthy of an 'away day') and then supported with regular in-house training.

Last month Anne-Marie Osbourne-Fitzgerald, Clinical Development Nurse, with (her) Clinical Manager, Denise Banks (Cygnet Hospitals), met Michael Doyle (Univ. of Manchester & Edenfield Unit, Prestwich Hospital) and I one evening at the Trafford Center in Manchester. Our two hour+ discussion covered the health career model, documentation, approaches to formal assessment and future plans (aspirations!). In the time available we obviously only scratched the surface, but Mike and Anne-Marie brought along examples of their paperwork.

Mike demonstrated how the health career model can be used implicitly or explicitly. At the Edenfield Unit the domains are being used individually to make up what is a standard A4 portrait form. The model informs their existing documentation; rather than the explicit form of the h2cm with the 2 x 2 matrix.
(I have a MS Word version of the latter and must update this to other formats).

Legally, as we know if it is not written down, recorded then it did not happen.
Educationally however, the objective is also to get students - practitioners - to think - before they do.

Anne Marie's documentation example at Cygnet Hospital included The Recovery Star:

http://www.mhpf.org.uk/recoveryStarApproach.asp

As you consider the star's points against the domains of the health career model - where in the model are you?

Can this provide another means to define 'care pathway'? A way that is not masked, hiding behind political, policy rhetoric (and really service-centered)? There are without question some excellent tools available, so care needs to be taken not to re-invent the wheel - hence your literature search. In some tools the effort and engagement of patients, carers and the public is exemplary. It seems what is needed is a hybrid solution. There is no single measure.

It may not sound scientific, but the complexities of care mean that academics, clinicians and managers must resort to a pick'n'mix approach. There is a battery of evidenced tools each with their history, application context and issues log (Why not? Lack of the latter might denote that such tools are no longer in development / review). As a clinician also involved in training, managers need to listen and make some tough operational decisions. The comms 'traffic' between clinicians, their managers, and senior managers needs to improve even more. Since, just using the above as an example, the STAR approach may find us on a ramble in the humanistic domains, the constraints of the mechanistic domain prompts the clinician's to ask:

"If you want me to use this assessment tool, what other thing do you want me to put down?"

As we are all aware: There is only so much time in a day, week, month, quarter. ...

In follow up emails I directed Anne-Marie to -

http://www.p-jones.demon.co.uk/contexts.htm

If you scroll down there is some discussion and graphics I did quite a while ago. This deserves revision as per the rest of the website, but the ideas are there I believe which can inform your project George?

Back then - and here on W2tQ I have been trying to demonstrate the wide range of contexts to which the health career model can be applied. In our meeting that evening the well established Tidal Model was also noted. This has of course benefitted from specific development, as per research that has produced audit and evaluation tools (Stevenson, et al. 2002).

It might make a useful reflective article – or at least a conference presentation. Ideally it would lead us to a measurement or observation approach ...

I would relish the prospect of a paper George, or a conference presentation. Not just contributing as a co-author/presenter, but supporting and enthusing new authors. The 21st century belongs to our students. Hodges' model can act as 'stellar' nursery not just here in the UK and EU, but globally. And not just in our respective disciplines (mental health, palliative - end of life care, forensic nursing care), but in informatics - conjoining and championing the need for socio-technical perspectives.

In addition to the above and thinking before they do, all health and social care practitioners must be able to reflect after.

As one of the original purposes for the model in my initial interview with Brian Hodges, research work addressing these are much needed.

This conceptual framework can offer much in case formulation, evaluation, clinical supervision, patient, carer and public (health) engagement.

[In short -] Can we measure Hodges' model?

George K. (Prof.)

You started with a big question George and similarly here at the end.
We have to be able to do this. In the first instance taking apart your question - there are clearly several questions here:

PRACTICE:

Above you noted that:

This could provide a framework for all carer-focused interventions in a broad way. As always, it would imply that carers need to have their needs addressed in terms of science, sociology, politics and interpersonal needs. As I see it, the first step would be to ‘map’ the carers’ needs onto that framework (from publications, if necessary from carers themselves).

It would be interesting to consider the formal process and practice of dementia care mapping against Hodges' model. Perhaps the approach you seek is something similar? If carer's make use of self-assessments these e-documents might act as an input for text analysis tools? If appropriate you could also weight certain items according to the priorities of carers? This would build on other carer research adding validity to your 'final' objectives.

Carers and clients (patients, service users) can with due explanation, appreciate the health career model. The model has a role to play in health education. I can well imagine a proforma similar to the Recovery Star example above, but purposed for carers and underpinned with the health career model. We also need to remember the spiritual domain, which is collective.

Ultimately George, your question concerns our ability to measure holistic, integrated, person-centred, multidisciplinary care and to state the obvious: there is no single measure to do this. Several tools and approaches gathered within a conceptual framework might however provide an environment favourable for a hybrid measure to emerge - literally a cycle?

THEORY:

In the paper you referred to George - Grande. et al. (2009) state:

In parallel with the lack of empirical evidence, there has been a lack of theoretical and conceptual models for when and how support provision in EOLC should improve carer outcomes. To guide further research, palliative care may here benefit from drawing on models within other fields, such as gerontology, sociology or psychology. p.341.

I am biased, but reading the paper the potential of the health career model as a high level tool is convincing just from a 'disciplinary cross-match'. Intra-, interdisciplinary, metadisciplinary and transdisciplinary perspectives could be a focus. This in addition to the specific knowledge and practical domains of sociology and psychology and as the authors note models therein. I forget the reference at the moment (and will check), but I recall carers / family units being framed in terms of strengths and weaknesses. That is, events, characteristics and relationships impact on a family with either additive, subtractive or neutral effects. This would seem applicable here?

While Grande et al. (2009) note that the (informal) carer's role is hidden (and is routinely described in this way) I wonder if in palliative care there are other dimensions that accentuate this 'hidden, covert' role?

The politics of potential death and actual dying may be another factor the health career model can help illuminate in a constructive, enabling way? Health care, patiency, sick roles, caring are always mediated by 'politics'. Hence the need for a political domain in any conceptual framework that Grande, et al. may consider. On a negative front, the model might also illustrate alienation and related concepts?

In conclusion!

Thank you so much George and Mary for my being able to share your initial thoughts here and respond with some of my own. I hope this helps you take your work further? There may be a few points to follow, which I will add and as you have noted above there is much that could be done to take this further.

Peter J.

From: Waldron Mary [mailto:MA.Waldron at ulster.ac.uk]
Sent: 06 June 2010 17:49
To: wg.kernohan at ulster.ac.uk
Subject: Carers Support Evidence

George,

Jury's still out on the effectiveness of support interventions and programmes which support carers in palliative care. Not enough research. Lack of evaluation, lack of rigour, no conclusive research, but lots of policy advocacy of carers support and addressing of needs. Sample of lit attached.

Mary A Waldron,
Research Assistant,
School of Nursing,
University of Ulster.

Many thanks George and Mary for your ongoing interest, and to Anne-Marie, Denise and Mike.

Reference:

Grande, G. et al. (2009) Supporting lay carers in end of life care: current gaps and future priorities, Palliative Medicine, 23: pp. 339-344. DOI: 10.1177/0269216309104875

Stevenson C, Barker P and Fletcher E (2002) Judgement days: developing an evaluation for an innovative nursing model. J Psychiatric and Mental Health Nursing, 9(3), 271-276.

Stellar nursery image
My source: http://media-2.web.britannica.com/eb-media/60/21260-004-3C62CA58.jpg

Reading the signs - Idealised Care

With the axes of the health career model labelled and the care domains - that fall between - identified, what can we read into and from the health career - care domains - model?

What basics of care and caring can we find there, what assumptions can we jump upon?

Here is a list ... (which also illustrates how the model grows with the learner) :)

• Health, well-being and social care are not declared in the face of the model, this suggests the model is high-level - generic.
  
• Health care (here) has at least seven disciplinary degrees of freedom:


• Sciences (biology, physics, chemistry)
  
• Politics
• Psychology
• Sociology
• Spirituality

• Health and social care theory and practices are reductive.
• Health care involves the traversal of space - distance.
  
• Health and social care has the potential to be depersonalising and alienating.
• Health and social care is simple and complex.
• The environment is inherent within the model in its varied forms.
• There is a moment of imbalance within the INDIVIDUAL - GROUP.
  
• Context is essential as a means to situate care (co-ordinate in an 'x','y' sense).
• The means is provided to situate the care context in a person-centred way.
• This model provides a template for personal and group reflection (shallow or deep).
  
• The model is open in terms of the final content, the content as expressed in care approach, philosophy, discipline, description (concepts, problems, priorities, strengths, a 'mash-up') is not dictated.
  
• In acknowledging the existence and primacy of the individual (located at the top so - must be important), the model provides a (potential) focus and vehicle for individualised, personalised, person-centred care.
• Whilst individualised care is at the center of care theory, practice and management, it cannot be defined purely by virtue of the INDIVIDUAL-group axis and the claim of an associated INTRA-INTERPERSONAL care domain.
• The individual must also be considered as a POLITICAL entity, a citizen, a legal entity that falls under the auspices of human rights. As such the individual is someone who can (or has previously) expressed their choices, wishes as to their health, care, well-being, best interests.
• Being an INDIVIDUAL within the family of humankind - 1 of some 6.x or > 7 billion - this person is unique and deserving of highest quality care, dignity and respect that should be accorded to all people.
• Health and social care whilst organisationally distinct (POLITICAL - POLICY) are to the INDIVIDUAL and carers (GROUP) concurrent, transparent and ideally integrated activities.
• Physical care (SCIENCES) can be, and is, defined in mechanistic terms; for example, time (objective), events, place, outcomes, observations / data (discrete, quantitative).
  
• Physical care is hence primarily objective.
• Emotional INTERPERSONAL care can be, and is defined in humanistic terms; for example, time (subjective), communication, responses to events (behaviour), feelings, beliefs, relationships (SOCIAL), expectations, fears, observations / data (subjective, qualitative).
• Physical care, emotional care is often mediated through the SOCIAL domain and the group - the family unit.
• Since this model indicates an initial structure and content the model is of potential use as a reflective resource for novice through to expert.
• The model is generic and as such not limited to health and social care.
• Such is the generic nature of the model it can support all learners in lifelong learning.
  
• The Spiritual is not there: it is ineffable. It is everywhere, everything, every'I' and everynow.
• Time is inherent in several forms within health and social care.
  
• The economics of health care is infused to all the domains, notably in the first instance to the SCIENCES and SOCIAL domains.
• The economic effects upon the individual in a humanistic sense, may be remote, but is inverse in terms of its impact.
• The model reinforces dualism: mind - body (but cognitively innoculates also).
  
• In highlighting boundaries, dichotomy, limits the model can stress the need for integration.
• The model suggests an antipodean fracture in relationships*: the patient and clinician (across physical care and mental health) inhabit the Northern hemisphere; while the carer (public), manager and policy maker the Southern.
• Health and social care is grounded in human communication (and that which is mediated).
• 'Sense making' must be a key issue in health and social care.
• Given the scope of the model, technology must be making a major impact across all fields of health and social care.
• The model can simultaneously represent the SOCIO- and the -TECHNICAL.
• A great many (potentially - all) values and standards are inherent in the model.
• This model can be represented using many media.
• This model is open to the Management Consultant's delicacy alphabet soup, i.e. using letters to represent approaches / methods, e.g. 4P's, 4C's.
• Health and social care can also be described holistically.
  

*Clearly, given the relationships and issues that arise this bears further examination and discussion.

This list is subject to revision - addition.

Image source:
http://en.wikipedia.org/wiki/File:Antipodes_LAEA.png