Physio-Political ... musings, songs and dances...

Just as the weekend dawned I shared Hodges' model as a loop-the-loop when it comes to interdisciplinary crossover and cross-fertilization. In that post I ventured that PHYSIO-POLITICAL is probably the one that is least familiar in health. What do you think - the four candidates being -

SOCIO-POLITICAL
PSYCHO-SOCIAL
PSYCHO-PHYSICAL
PHYSIO-POLITICAL?

If I had to justify PHYSIO-POLITICAL as least familiar, it is one of the most obvious individually; in that if you lose your freedom of movement, or freedom of expression and self-determination you are going to make a real (rather on-the-spot) song and dance about it.

Perhaps this is why it is only in the past few decades that disability rights and disabled access have come to fore in health and social care and government policies and law. There is also a realisation with ageing populations the extent to which PHYSIO-POLITICAL impacts on our quality of life. If you cannot transfer from chair to toilet let alone walk - that spells 'trouble'. This is a double-whammy when allied with the PSYCHO-PHYSICAL, suddenly cognitive abilities also enter the frame.

The 'PSYCHO-PHYSICAL' is mentioned in Gardenfor's book Conceptual Spaces (more on that to follow too), which set me to wonder that each of these disciplinary fields needs to be revisited regularly in policy terms. For example, bound within the socio-political is economics with the problem of poverty ever present in the news.

For individuals with learning disability from a psycho-physical perspective they may be further compromised with the social emphasis on visual, health and ICT literacies and the information society plus a reduction in the meaningful activities they can pursue. This is a difficult debate (raised in the literature I notice), but one that needs to be addressed.

If people also lack the mental capacity - PSYCHO-POLITICAL - to make decisions for themselves then PHYSIO-POLITICALLY speaking they will depend on others to make that song and dance on their behalf.

(I never expected to get so caught up with hyphens - weird that - when I originally selected the domain name for the website over a decade ago I used a hyphen. ...)

Holistic Care: Squaring the Wheel of Disciplinary Domains

Over the past two years on W2tQ, I've defined h2cm in several ways, covering the model's axes and care domains, houses and sailing....

In January (2008) a dialogue was posted with Barbara Rylko-Bauer who shared some very helpful thoughts and suggestions on the model's name and the incorporation of culture and economics into the title of the respective SOCIOLOGY and POLITICAL care domains.

Thinking around this and my still limited (frustrated) reading of Michel Serres' and others I realised that the axes can be replaced with hyphens. This subtraction results in an interesting addition to the model's structure, perceived and potential content (domains).

Around the time the links page content were justified (or not) I also posted about the INTERPERSONAL domain and how this domain is more accurately described as the INTRAPERSONAL. That particular point was about a domain, but Barbara's point invited much more. Four hyphens certainly don't deliver, but the focus here has shifted:

the scope is not 90° but 180°

The hyphen forces contemplation of two domains and the axis in-between. See what you think:

Although hardly novel to geographers and those of a political bent 'PHYSIO-POLITICAL' is perhaps the most unfamiliar of these terms to people in health and social care - outside of public (mental) health - about which more to follow. ...

Soft thinking: Care Ideals & Real World Constraints

It would be marvellous to be able to practice comprehensive care in terms of assessment, planning, intervention and evaluation (apie). In reality of course the world at large conspires to upset the best laid plans. Let's call them constraints it sounds better.

Away from the theory there are so many constraints in practice that maybe they should be reflected in software applications or e-learning on Hodges' model? Now if you are looking for rocket science then please read no further, since what follows does not even qualify as a plastic bottle rocket project.

Let's imagine we are creating a data entry form for Hodges' model. Users of the form can specify a care domain and enter a care problem. The first constraint and a true reflection of the real care world is that the number of problems 'allowed' is limited; it might be 3 per domain, or something like this:

intra-INTERPERSONAL = 3
SCIENCES = 5
SOCIOLOGY = 3
POLITICAL = 4

So there's an essay for you: What would your total be? What if the fifteen possible problems can be allocated with the further constraint that a domain cannot exceed five in total? Does there need to be a minimum of at least one problem in a domain? What year is it? Are 'problems' a bit old hat? What about the individual's strengths?

If on completion (whenever that may be) the patient (plus carer...) has defined a set proportion of the problems, then there is one measure of holistic care. A further holistic measure could be the number of ticks for those four stages of care - apie. It does not take much when painting with care constraints and numbers to find complexity. And this does not even touch the surface.

Person-centred care: "Right! Down! Down! Riiggghhht again! Spot On!"

-|- Person-centred care is one of the Grails of health and social care. It is up there with holistic care, which it precedes since holistic care needs a subject (discuss?).

In terms of Hodges' model the 'person' (for me) is to the upper-left-of-centre. Why there? Well, you really understand why when helping people cope through dementia.

It is no surprise that the development of person centred care and personhood have been especially concentrated and emphasised in the care of people living with dementia.

They need to be and constantly refreshed too - everyone forgets - some of us more than others.

Physically of course 'person' translates to the upper-right quadrant. So there you have it - in the INDIVIDUAL-group axis the classic dichotomy-debate: MIND-BODY.

I have no argument with the need for person-centred care, but faced with a Grail and the bright light that can encompass it, safety and respect dictates we step back. From a distance we can then see that person-centred care is only part of a much bigger picture.

At the end of the day (and night!) we need to be centred full-stop.

If not then saying the words that count such as dignity, respect, choice, privacy will echo in the intra-INTERPERSONAL domain and make everyone feel good in the SOCIOLOGICAL domain. All very worthy but possibly without making an impact where it counts - in the POLITICAL domain.

By placing the person at the centre of Hodges' model ALL the
domains are ready to hand and mind.

Holistic Bandwidth [II] 16, 180, breadth, depth and thoughts initial

If we were able to put the care record into an appropriate text analysis program is there a measure of the conceptual span - the holistic bandwidth of care - somewhere in there? Could there be a disciplinary or task-based mesh, a tag cloud that could be superimposed on Hodges' model to represent care as holistic bandwidth?

Very early on in the web site's history a page was added on the multicontextual nature of health (and social care). This contexts page like the others has not been properly researched, which I recognise is a risk for readers in terms of 'evidence based sources' and a risk for me since of course the Web is a rather public arena to air initial thoughts.

Since the site and this blog are a call for research in this area, I'm sure a search would reveal a literature, but without recourse to said literature I'm not sure how explicitly - my incomplete - notion of holistic bandwidth has been studied in care contexts. On the context page I included several basic diagrams to indicate how Hodges' model might be used as a 'measure'. This page plus the others need revising with a bin (icon) close to hand, in the meantime how can we measure holistic bandwidth?

We could add the problems identified in each care domains, e.g.:

INTRA-interPERSONAL = 3
POLITICAL = 2
SOCIOLOGY = 5
SCIENCES = 6
= 16

Continuing in a fit of numerics we could throw in some multiplication - 3*2*5*6 = 180 ?
'180' is much more impressive than a paltry '16'.

What next...? Could the domain scores be weighted in some way? Is it valid to assign a primary domain? And while we are at it where does self-care fall (intra-interpersonal surely)? Wither the literary heavyweights of severity, chronicity, strengths, recovery and well-being. ...? Oops - how could I forget - dependency measures are nothing new; but the literature bearers are not the issue.

If we still frequently fail to deliver holistic care, then what is holistic bandwidth (actually measuring)? Is it -

• The scope of care [in one or all of - assessment, planning, intervention, evaluation, outcome]?
• Simplicity [breadth]?
• Complexity [breadth and depth]?
• (Rapid) care integration [time, connectedness]?
• Concordance: clinical problems + patient (carer) problems + outcome set?
  
• ....?

Serres-Hodges model chapter proof & Oamos

I've received the proof for the book chapter to appear in:

Social Information Technology: Connecting Society and Cultural Issues
edited by Dr. Kidd and Dr. Chen
IGI Global

Exploring Serres’ Atlas, Hodges’ Knowledge Domains
and the Fusion of Informatics and Cultural Horizons

Abstract

This chapter explores the extent to which selected writings of French philosopher Michel Serres and a health care model created by Brian Hodges in the UK can augment and inform the development of social informatics. The volume of Serres’ output contrasts markedly with work devoted to Hodges’ Health Career - Care Domains - Model. Since the concept of health is universal culturally, and informatics disciplines are emerging fields of practice characterised by indistinct boundaries in terms of theory, policy, and practice, various ethnographic and cultural associations will be made. Placing Hodges’ model and Serres' work together is not intended to suggest direct equivalence, other than the common themes this author intends to bring to the attention of the social informatics community. Central to this is the notion of holistic bandwidth, utilising Hodges’ model as a tool to develop and disseminate sociotechnical perspectives.

-<>-

This has been a long road, but it is smashing to see your text nearly there as 'chapter 7'.

To close here is a new media search engine:

http://www.oamos.com/

Holistic care striking a balance: Dance halls and the steps we take

I was reminded recently of these research related terms:

NOMOTHETIC -

Of or relating to the study or discovery of general scientific laws.

IDIOGRAPHIC -

Concerned with establishing the uniqueness of a phenomenon:
an individual, a place, or a region, for example.

These words struck me due to the way that Hodges' model can encompass them courtesy of the INDIVIDUAL-GROUP and HUMANISTIC-MECHANISTIC axes.

You know those arcade and now home based interactive dance games where the player dances on a pad?: well if Hodges' model is a dance hall and the concepts we use (the semantic web) comprise the dance steps; then if we focus on one side only (self?) we would essentially be standing on one foot - dancing with one half of our body or may be even a quarter.

Come on.
Yes of course - "at your own risk".
Stand up, move the chair out of the way and do your groove thing!

Try it!

Do you feel a bit silly?

OK, OK, it's no use,

Alright!

I confess!

While I try to be holistic, that's how I dance...

Image source adapted from:
http://www.uniqlo.jp/mixplay/

Little boxes, little boxes ....

We are obsessed with 'boxes' - many of us especially so - at this time of year.

We cut and dice Nature into categories - boxes for things and concepts. Leaving the car and aircraft aside, being somewhere else - means thinking out of the box. Materialism? Well that is thinking out of the box taken to the extreme since materialism has us:

• filling boxes
• shipping boxes
• and the populous buying the latest and greatest of them.

(What would I like for Christmas? Well, I could really put a MacBook to good use - please!)

It used to be you shook the box - something rattled. These days silence prevails. The contents are virtual. The only rattle is from the dosette boxes. Count them out - M:T:W:T:F:S:S....

Science and medicine in particular has a thing about boxes. Of course, I have to put my hand up here as Hodges' model is not exactly quadratically challenged. It's rather ironic that in order to think out of the box, Hodges' model encourages us to think in four or five (spiritual) of them!

The business community is equally obsessed. The box clichés abound loud and clear in group, consultancy and change exercises. Of course the problem is when we only think in one box then things can come unstuck. They are often blinkered and this makes sense at times. As mentioned previously, medicine very frequently has to deal with life saving interventions that need snap decisions. I don't think it would go down very well in a crisis that someone pipes up "Now hold-on everyone we need to reflect on this, let's proceed in an holistic manner." At other times though critics point the finger, when people are treated purely in a box called 'SCIENCES' and the person becomes a mere adjunct to the box: a sticky label with a diagnosis (or two) written on it.

Nurses pride themselves and their person-centred caring approach on seeing the individual, not just the diagnosis.

Health professionals spend several years getting to know their box(es). The SCIENCES anatomy, biochemistry, physiology... Now in medical training doctors spend more time on communication skills. All health and social care professionals are prepared to 'travel', i.e. to put themselves in the patient's (carer's) shoes and see the world through their eyes. Increasingly in all human activities one discipline depends on the combined contributions of many others. Maybe that's why there's so much emphasis on words and disciplines like - integrated, transdisciplinary, socio-economics, interdisciplinary, psychosocial and geopolitical. New disciplines like neuromarketing emerge which we can expand in the respective boxes - e.g.

• INTRAPERSONAL box: behaviour, experiments, priming, freewill, ethics, personal choice, memetics
• POLITICAL box: consent, advertising, legislation, neuroeconomics, public health, governance-control, measures
• SCIENCES box: functional-MRI, bioinformatics, research programmes
• SOCIAL box: media, language, mental pollution, social nets, cultural acceptance, public perception

Using the model and 'travelling' you don't have to think of it as being 'in' or 'out' of boxes. Draw Hodges' model on A4 paper:

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

OK, now mentally fold it - one way - then another.

Suddenly disparate ideas, issues, techniques are thrown together. As physicists show (in theory only alas) as our learning grows, our previous journeys (new experiences - role plays, placements, secondments...) mean we don't have to travel the full distance. You too can warp space. In addition you are better equipped to take the patient and carer (student, whoever) with you and (try) to get their engagement.

It's true that many of these combined horizons may not work, but that's the nature of risk and creativity for you. Boxes! Do take care how you handle yours. Look out for those edges too - the leading edges change constantly....

Image source: Copyright © 2007 Apple Inc.

SCIENCES links: Holistic Bliss or Tristram Shandy ... V

Finally: what of the content of the SCIENCES links page? Firstly, a little background -

Hodges' model has a key role to play in engagement. In health this means helping people to help themselves. Assist them to use the knowledge and experience they have of their illnesses. When necessary educate them - patients, carers and the general public. Use the latest research to further health promotion and preventive measures. These efforts, these messages though must compete with an awful cacophony of noise - political and cultural in the media - that is frequently itself awful dross.

Little wonder then that the science, educational and political communities are so concerned about the public switch-off, with citizens ill-equipped to critique and engage in debate on key SCIENCE issues - biotechnology, nanotech, astronautics - funding!

Engagement is not for everyone of course, but surely we can do better this?

Over on this right-hand MECHANISTIC side of h2cm what should political expectations (aspirations!) be regards the holistic bandwidth of a given citizenry? What does the 21st C. curriculum for the citizen look like? Is it as taught, the written, the learned, DIY, the 'take away', the media delivered or the hidden, ...?

Back to the task at hand: Like all the links pages SCIENCES also places health related subjects uppermost for ready access together with selected conferences. Not surprisingly ANATOMY & PHYS are first on the top row, followed by selected NURSING AND CARE THEORIES. If the h2cm website has any roots as a project it started here and spread.

The media in general and IT commentators in particular stress information overload. The relentless increase in the volume of information year-on-year has a prime contributor amongst the research community in medicine.

When we speak of General Practitioner (family physician) it seems increasingly difficult to determine what is general? There are so many branches of medicine even before specialised directions must be taken. The costs and risks associated with 21st C. medicine mean that filtering the research literature to find the treatment pearls is crucial to effective practice, outcomes, management and policy. So, EVIDENCE BASED PRACTICE (EBP) that utilises e-libraries and electronic databases is the tool of our times and with QUANTITATIVE RESEARCH completes the top row.

Before moving down a peg (if digression sensitive turn away now).

If you look at Hodges' model and its quadrants with a nurse's eye, you know for intramuscular injections the dorsogluteal - the upper-outer quadrant of the buttock - has been cited as a preferred site. How fitting then that the upper-right quadrant in h2cm is the SCIENCES. Problem is of course upper-outer translates as upper-right AND upper-left and sticking needles in people is a pretty invasive and mechanistic task. That upper-outer LEFT quadrant in h2cm translates to the humanistic [INTERPERSONAL] domain, so sticking needles there may be anatomically correct, but epistemologically speaking where are the talking therapies? (The model also at this point invites dialogue and debate on addiction.)

Recently, I've been researching a paper on socio-technical structures (which will also attempt to explain the hyphen), this project-making or -breaking conjunction of the social and technical for me begs the question of the locus of INFORMATICS. There are many schools of informatics in addition to HEALTH INFORMATICS I & II. If it is sensible to ask of these informatics fields, which h2cm domains would they claim as their primary home? [COMMUNITY INFORMATICS is listed in the political domain.] The great and ongoing efforts in CLINICAL CODING AND CLASSIFICATION within medicine are also listed here.

I've often wondered about how much duplication there is in the various electronic databases that are available? What metrics would you use? There's a major Phd study for someone there if not already completed or under way? We see rationalisation in other industries, business sectors until then (or the semantic web) the plethora of available resources in INFO SOURCES further extends EBP. In artificial intelligence pruning the search is an essential strategy. Is the internet tree still growing or shrinking? I understand it is actually shrinking - rationalisation has begun?

The next three categories represent a key personal interest of mine. IMHO graphics, diagrams and visualization can help conjoin health, informatics, h2cm and the wider world; hence DIAGRAMS and VISUALIZATION I & II. Is there a role for DIAGRAMmatic reasoning in health and social care?

It could be argued (and has been) that visual literacy is yet another educational milestone.

PROGRAMMING is great fun - if you are not concerned with hydraulic control systems, air traffic control software, or clinical systems. MARKUP LANGUAGES variations of XML have proved revolutionary. In reading about and my initial tinkering with Drupal, XML is in there (and so much more). In education and nursing theory much is written about the need to bridge the theory-practice gap. Perhaps the gap is necessary: a velodrome has to have a centre. XML is a software technology that can bridge gaps in transforming data, information and knowledge.

As in other domains I wondered where to place ENVIRONMENT & ECOLOGY? In the four introductions to the website, I've stressed the relationship (dependency) between green issues, health and our quality of life. ENVIRONMENT & ECOLOGY should ideally reside in each of the domains, or at the centre the 5th domain - the spiritual - made up of all four.

Our VIRTUAL creations and worlds are presented next. IF you want to conjoin data sources, users, and present information & engage users, THEN use the senses that are available. Health and social care records can benefit from visualization as tantalisingly glimpsed in early work on visualization in the social sciences. (I'll see if I can switch these around a bit.)

Next: ASTRONOMY: Orion - you started this journey from my bedroom window. Rising in Winter standing tall then giving way to Spring. We need to give the real stars back to the people:

Turn off the light,
take a deep breath and relax

[Engima - Mea Culpa]

SCIENCE could comprise so much more space permitting just one scratch of this surface - pharmacology, chemistry, physics the new disciplines all deserve listings of their own.

SCIENCE is most clearly evinced in MATHS & LOGIC that provide the basis for ENGINEERING. The final two categories return to programming. Compared with the others this final row is smaller. I have to contain this pantological journey. The H2CM links pages are big enough: I know my limits.

The final category RUBY [TOOLSET] is perhaps poetic justice since programming is oft described as SCIENCE and ART. One thing that Hodges' model is about -

folding time and space.

Naive holism, Hodges' model and a lesson from NeuroLinguistic Programming

The pen is mightier than the sword.

Words are indeed very powerful, which means we should be careful how we use them.

In the mid 1980s when artificial intelligence (AI) had a temperature well above normal limits, personal studies brought me to the words that represent commands in expert system and artificial intelligence applications. The question - how might language influence our expectations of such programs? In what was a major personal project at the time (which never saw the light of day - but whose effects may be evident in the main website and this blog?) I discovered and referenced work on problems discussed by McDermott (1985).

This included the choice of mnemonics used in AI programs, with McDermott comparing the mnemonics in two systems - Planner and Conniver.

True: things have moved on - but history, history....

Planner : Conniver
GOAL : FETCH & TRY-NEXT
CONSEQUENT : IF-NEEDED
ANTECEDENT : IF-ADDED
THEOREM : METHOD
ASSERT : ADD

Upon executing 'GOAL' or 'THEOREM' into a computer 'you can just feel the power at your fingertips. It is, of course, an illusion.'

'If a researcher tries to write an "understanding" program, it isn't because he has thought of a better way of implementing this well understood task, but because he thinks he can come closer to writing the first implementation.' Ibid.

Legally, today the world is very different and yet without care extreme enthusiasm and the market may blur our vision and (rather ironically) dull our reason; McDermott observes that:

'If he calls the main loop of this program "UNDERSTAND" he is (until proven incorrect) merely begging the question.' Ibid. p.144.

I believe there is a similar lesson in terms of 'holistic care'.

As the track is swept and the starting blocks are put in place for decision making in the clinical forum - what sense are the users to make of the language used? Will eagerness to engage ("wow!") the user community cause a false start and what might the impact be?

Words are like sub-atomic particles: strange, ordered, chaotic, true, honest, noisy, quixotic.

Repeat some over and over and they become nonsensical.

Repeat yet other words over and over at the behest of those who know and they
conjoin, concatenate
to become belief-bearing,
an energetic property with a sharp edge that can turn the tide of history
(departmentally, locally, nationally and globally).

Here are (just) two reasons why holistic care has proved so elusive:

1. It is easy to add 'holistic' into care and ward/service philosophies and policies.
   
2. Actually measuring holistic care is not straightforward, but the measures should be specified as the word is first used - enacted. (If the service in question has someone working in a professional practice development role this might well fall to them.)
   

The usual outcome is what we might call 'naive holism'. The word is there in policy (for all inspectors to see). There are concerted and authentic efforts to step beyond the physical and the interpersonal domains, but there is still much to do. As for the social and political - maybe tomorrow.

If such a thing is possible an evaluation of 'holistic bandwidth' would of course need to be done at upon completion of a care episode. Maybe there is a test...?

While physicists struggle on with it - perhaps String theory can assist us? More to follow....

McDermott D (1985) Artificial Intelligence Meets Natural Stupidity, In MIND DESIGN, Haugeland J (Ed), MIT Press, London, p.144-145.
(I hope the quote is correct - old notes - and no time to check, but you have the gist).

Holistic Bandwidth: All or Nothing

Quite a few years ago (Jones, 2004), I took the term bandwidth from the information and communication technology (ICT) world and applied it to health and social care. We seem to have been trying to achieve holistic and integrated care for decades. When care assessment, planning, intervention and evaluation is limited in scope this creates a narrowing of perspective, a bottleneck. Just as bandwidth problems used to affect the quality of on-line experience, so the bandwidth in health and social services ultimately affects the quality of care.

There's nothing wrong with perspective.

It's essential to making sense of the world. And after all, that railway line travels all the way to the vanishing point and it doesn't stop there. Road or railway - there's enough space reading between the lines to launch a whole film and literary genre.

I've said it before – but it really is ironic that many of the constraints in ICT have been overcome through broadband, memory costs/capacity and multi-core processors; while health services still struggle, still need to change:

From DISEASE - TREATMENT to PREVENTION - ENABLING ...

Single-track thinking is no longer sufficient, even if it is reassuring being able to see where you came from.

There’s an interesting non-trivial aside that follows from this bandwidth notion. The old conundrum of quality versus quantity.

Quality and quantity are the ties that bind, the Gordian knot. Cut this one at your peril!

Failure to focus on priorities, to take in that single, that utmost life-threatening perspective could result in disaster. Intensive care is the obvious example. Failure to attend to the physical priorities because of what seem new-age, airy-fairy ideas will quickly get you noticed.

There’s probably a paper out there on quality, quantity and appeals to holistic care. Returning to bandwidth I have wondered about how to measure this? Integrated care pathways and variance might be one approach, serious incident reports may be another revelatory approach? If it’s a care concept and moves ((uses energy) has currency) measure it!

There are a raft of measures for all sorts of things including, mood, behaviour, nursing care related, quality, risk and dependency. If you know of any that might measure holistic bandwidth, please let me know and add a comment here.

In the meantime I’ll ramble on - travelling h2cm's tracks…



Jones, P. (2004). Viewpoint: Can Informatics And Holistic Multidisciplinary Care Be Harmonised? British Journal of Healthcare Computing & Information Management, 21, 6, 17-18.

Gordian knot image c/o Bernice Steinbaum Gallery.