Fundamental-ism lost to nursing

Nursing, health and social care are full of fundamentals:

- of care, aims, objectives, arguments, issues, targets, values ...

- and much more besides. Fundamentals fuel and provide the oxygen that sustains the research literature and media. Fundamentals are the constant heat for education, practice and policy. Amongst the definitions of -

fun·da·men·tal (fŭn'də-mĕn'tl) there is

Basic, base, foundation, central, core, essential, necessary, key, primary, significant ...

Language is amazing in how far a short detour can take us.

Fundamentalism has always been associated with religion and of course no less today; when the literal reading and interpretation of religious texts means that fundamentalism is tainted by beliefs and actions that extend from intolerance, through to extremist tendencies and terrorism. Fundamentalism in this extremist religious guise is not the focus here.

Looking at nursing text book titles fundamental still sells. At times seeking out high standards of nursing care makes you wonder whether a fundamentalist reading of nursing (and human rights) is needed?: and as you get older the need gets ever more acute.

In our informationally overloaded world maybe the message of high quality (fundamental) basic nursing care is lost in the noise. The problem I believe lies in the other meanings of fundamental -

Physics.
a) Of or relating to the component of lowest frequency of a periodic wave or quantity.
b) Of or relating to the lowest possible frequency of a vibrating element or system.

This means that even though those low frequency, infrasound messages can travel an awful long way and strike an occasional significant ethical chord: the population at large is hard of hearing.

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.

Care Architects in an Era of Care Ecology

Not everyone is an Architect. And yet we are all architects at certain times when a proposal with its accompanying design, construction and commissioning challenges comes along. The difference is formality (the law) and scale: ultimately we the 'architect' may defer to the professional.

Similarly, we are not all Doctors, Nurses, Social Worker, or Occupational Therapists... although we may have played these roles in imagination and in taking on day-to-day diagnosis and problem solving: Do I(we) need to consult? Like a bandage there is a twist here -

You see, we are all Care Architects.

The duty of care is quite an extensive concept. The call to reach for the T-square and drawing desk will hopefully be infrequent, rare even, when we do the starting point is the problem at hand, whether that hand is injured, tonsils are swollen, belly aches or our mood is low.

There are set points in our lives where personal administration is a necessity. The tax return, dental checks, the renewal of insurance policies, eye-sight check-up. It is nice when these things look after themselves, these days we even have e-prompts to jog us into action.

Looking at Care Architecture as a whole - as a Care Ecology - this ecology has another starting point; one to which the individual / patient does not usually have ready access. The medical record. If this is not our starting point, it is for the health and social care workers (although there are many constraints that operate for these Care Architects). More and more is being expected of us as individuals and members of groups - be that as 'patients' or 'citizens'. A primary example is HealthSpace:

HealthSpace is a secure online personal health organiser. Anyone over the age of 16 and living in England can open a HealthSpace account.

HealthSpace is an initiative that is designed to acknowledge how we are all Care Architects at heart and part of a much wider care ecology.

As of Feb 2008 - once subscribed and depending on geography HealthSpace may provide the account holder with access to their Summary Care Record.

It would be very interesting to see the (h2cm) profiles of HealthSpace subscribers thus far. There's a marvellous MSc. - Ph.d dissertation there for someone. People with long term medical conditions or extended acute episodes may recognise the benefits of being actively engaged in contributing - writing to and viewing - their (own) medical record.

This engagement must be
a vital perspective
not a vanishing
point
.

What about the rest of us? How can we get over the personal admin-hump?

How can people be engaged in their health record? Health is the operative word here.

Elderly Care: "Follow me please" along the gangway

It goes with the job, seeing people in residential care and nursing homes. The past few weeks walking through several care facilities - corridor-lounge-corridor - you pass a series of open doors, an invite to gaze that way. (People do ask to have their doors left open and visitors should not be able to walk past open doors if privacy and dignity are at risk?) Walking along - a smile, nod of the head, wave of the hand it's like a gangway.

Recently, though it was a case of 1, 2, 3 and counting: residents sat in their rooms; chair, wheel chair, special chair bound.

A gallery of still-life studies. So many heads bowed, cast as life and world-weary statues. So many aged variations of The Thinker.

The homes and their staff do the best they can, some employ people dedicated to 'activities'. Despite this, it's not easy for many new carers to appreciate the value in engaging people who are disoriented for TI:ME, PLACE and PERSON in chit-chat or a group activity when five minutes later they have forgotten all about it. People are referred to mental health services because they have a mental health 'problem' and yet in many cases their bags are packed and they are ready to take you on a journey: if you care to listen.

We seem to focus on the cognitive value of the things we do, but is this a variation of task orientation that delivers a concrete output (PROCESS vs PURPOSE again)? What about the emotional value of the things we do and the possible benefits, whether visible or intangible? ALL work and the effort it requires carries a price and despite the forgetting, the emotional engagement and safe social contact can still make a real positive difference to people. The price paid by residents in being engaged in conversation, can reduce any sense of alienation, loneliness and the aggression and agitation that can follow.

What do I mean 'safe' social contact? Many people in care are disinhibited; they say things to their fellows and staff that are very personal and upsetting. Cognitive decline is a fact of life, but even for people diagnosed with dementia, the damage done varies from person to person. For many they are profoundly impaired and yet their personality flickers through and with it sensitivity to things said by their peers. Remember those anxious moments in the play ground? Social mores are deeply ingrained in us. Maybe this is why for youngsters the current spate of e-bullying is having such a impact. Bodies may be battered and worn, but INTRA - interPERSONAL and SOCIAL exercise mediated by carers (and relatives!) can pay longer term dividends.

In between care needs that also demand quiet, rest and sleep and our need to be realistic and objective; personal and group engagement can I'm sure make a real difference. It depends on the resources + the right attitudes to make it happen. To see the person not the statue.

Even if only for a few moments
bringing statues back to life is real magic.
Walking the gangway is one thing,
but residential care should not be the gangplank
as it is so often portrayed for residents or staff.
Converse-2-conserve.

Rodin image original source: http://users.ox.ac.uk/~ball0888/oxfordopen/Rodin.htm

i3: Inclusion, Integration, Informatics

As well as studying Bortoft over several months (time...!), I've been reading Oberski's (2003) paper 'A Goethean way of seeing inclusively' (ref. below) which discusses inclusion within special education. The second page in - I sat up. Although the subject is education, inclusion and integration are central drivers in care service development and improvement. Let's face it, you can't read or listen anywhere without coming across 'i' this and that.

Usually, ask a philosopher to justify their existence and amongst other earnest pursuits they will point to their detailed critique and qualification of the way words are used in our routine daily lives, both domestic and working. They do us a great favour, as the world would grind to a halt if everyone was blinded by the light of uncertainty and what would be perpetual philosophical deliberations.

In this paper, Oberski refers to sources that highlight some crucial differences between inclusion and integration. In this context inclusion means the school must adjust to accommodate and include the child with special educational needs.

As for integration, it is the child [individual] who must 'fall-in-line' and match themselves to the institution the school.

Of course, [special needs] education is not health - is it? Whatever the extent of education within health and social care, it must play a far greater role in future. That's why distinctions like this are important.

The policy push is ongoing - integrated services, public involvement (inclusion?), patient engagement (self-assessment, carer assessment, self-care = inclusion?). How does all this fit together and :-

1. is it generally consistent?
2. are these terms consistent as applied across the h2cm domains:

- INTERPERSONAL; SOCIAL; SCIENCES and POLITICAL?

There's an exercise here if you care to try?

Actually, if inclusion and integration are not used consistently across the care domains, what does that mean for #1 and the general situation? Surely declaring a conflict of definition - should any exist - is as important as declaring a conflict of interest?

If a conflict is found do we freeze in panic, transfixed in the glare of uncertainty?

Or do we just play it cool. Reach for the sunglasses and watch as informatics pulls it all together?

Oberski, I. (2003). A Goethean way of seeing inclusively, Eur. J. of Special Needs Education, 18, 3, 333-340.

Holistic care 3: Location

Through February and March I looked at holistic care definitions and other aspects. Now for location.

The place to look for holistic care is literally everywhere. Every - where?

Well yes, if we take holistic to really mean holistic.

There is the obvious physical where that applies in the various care sectors such as; primary, secondary, community and tertiary care and the places they all encompass and contain. The locations associated with buildings and other architectural and organisational structures however permanent: hospitals, hostels, surgeries and clinics, homes, schools, prisons, refugee camps and workplaces - including inner and outer space.

The other where comprises the cognitive and virtual. Our thoughts about care, the thought processes and conscious decision making about care assessment, planning, intervention and evaluation. Except in specific psychoanalytical therapies the unconscious is a less frequently acknowledged and yet undoubtedly factor. If values are to have an origin and a safe harbour (governance) then a light must be cast on the darker, uncertain places. Accepting and utilising these places facilitates a holistic perspective, an adjunct to the more usual analytically derived views.

Speaking of analytical: recently, working on a 2nd temporary secondment, I've been preoccupied (and still am) with PROCESS and CONTENT. We tend to lose ourselves in process; the nursing process, care process, process mapping workshops abound. The problems take centre stage and because they are the patient's problems that qualifies the process as being person-centred. A tick goes in the box.

At times outside of medical emergencies this may be a mistake.

In deploying 'IT' the argument goes that the benefits of information technology in health care (various reports, effective case management, safer practice...) should be transparent, that is -

a by-product of the care process: not an add-on.

To me this suggests that the care process, the energy spent negotiating the care pathway produces a reaction. Informationally this reaction can be desirable. (I'll leave you to contemplate the alternative.)

If the person is truly at the centre of care then maybe the reaction can also be characterised as precession? Just as the Earth precesses on its axis, so our care processes result in precession around the person - the 'whole' individual and their situation at the centre of care?

But only IF we choose to take notice, factually, emotionally and informationally.

There's no disputing that care is frequently wobbly. But this oscillation can provide a periodic peek into the four (5) care domains.

At times these presentations, or windows of opportunity may be physically and emotionally draining, and arise in a highly disordered manner, they are nonetheless there.

Allied with a problem space, that other for me essential location of holistic care, you have a potentially very powerful tool.

I know this may be twaddle and I may be on shaky ground, but at least I'm trying to follow the wobble...

As highlighted previously there are alternate ways of seeing.

Before I close and follow a countdown: Thank you Darcy - a star on stage : GO STS 117 stars in space.