Hodges' Model: Welcome to the QUAD

- learn about the conceptual framework Hodges' model. A tool that can help integrate HEALTH and SOCIAL CARE, INFORMATICS and EDUCATION. The model is situated, facilitates person-centredness, integrated - holistic care and reflective practice. A new site using Drupal is an ongoing aim - the creation of a reflective workbench. Email: h2cmng @ yahoo.co.uk Welcome

Monday, August 19, 2019

Grief, mourning and commemoration in the North

individual - PLANET
humanistic ----------------------------------------------- mechanistic
PLANET - population



August 2019
415ppm CO2




"Ok is the first Icelandic glacier to lose its status as glacier. In the next 200 years, all our glaciers are expected to follow the same path. This monument is to acknowledge that we know what is happening and know what needs to be done. Only you know if we did it."

Friday, August 16, 2019

"Finishing It" - Poems and Pills or poems On pills?

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

First work as Poet Laureate



Simon Armitage

My sources:
Laureate's poem on a pill aims to tackle cancer, News, The Times, 14 August, 2019, p.14.

Singh, A., A pill with cancer's name on it is Poet Laureate's first work, The Daily Telegraph, 14 August, 2019, p.9.

Image source:
Sutton and Croydon Guardian

Wednesday, August 14, 2019

2 + 2 = ?

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

2 + 2 = 5

a notice put up in Moscow during the first Five Year Plan, indicating
the possibility of getting the job done in four years, if workers put
their backs into it

Burgess, A. "1985", 1978

2 + 2 = 5 - stands out in three other senses:

Firstly, it stands politically for the healthcare enterprise as a whole, that is, the NHS, private sector, organisations of various kinds, volunteers, carers; plus theory, practices, management and being political let's add policies. This is due to the ongoing nature and level of political healthcare dialogue and debate. The Left, the Right, funding, history, public engagement, the electoral cycle and associated political party advertising.

The arithmetic above is a dialogue. A dialogue that lurches from politician's promises, to their knowledge that health care staff will still deliver. The health care workforce knows the logic very well: it is summed up in what is termed workforce planning.

Second, what I have previously referred to as 'legacy issue', those health care, health systems problems that have been ongoing problems across several decades as experienced (wrestled with) by successive professionals and today's new students and trainees. These are 'problems' by virtue of being:
  • poorly defined (often by their cussedness, not for want of efforts)
    • What is the history, the root of 'care' and 'caring'?
  • the siloed nature of knowledge;
    • by subjects, i.e., sciences, history, economics, sociology
    • dichotomised knowledge and concepts, i.e., mind-body, subjective-objective, quality-quantity ...
  • being universal;
    •  spanning the individual and group
    •  being national and global
    •  being global in Planetary terms
  • the need for multiple disciplines with the standpoints and interests that arise;
  • the dynamics of time: history, present, future;
  • The meaning of 'progress' - scientifically, technically, socially and politically;
  • Identity and personhood in the health context
    • Well-being
    • Ill-being
  • Integration of the above.

Thirdly, Hodges' model has four explicit care - knowledge - domains. In healthcare we must always have due regard for the spiritual dimensions of our patients, carers, community and the communities of practice that we work within. So, in Hodges' model, or more accurately encompassing the whole model and extending beyond it we must contemplate and be cognizant that 2+2 does indeed equal '5'.

Source: Burgess, A. "1985", London Hutchinson (1978).
Spotted in Sam Read's bookshop Grasmere.

Tuesday, August 13, 2019

Individual & Group process - Collective Intelligence [CI] c/o Radcliffe, et al. (2019)

No explanation is needed as to why this paper caught my attention in a tweet that featured the figure [2] below? The context is medical, not nursing and the extended multidisciplinary team, but as per the threshold concepts post the focus is decision making.

From a nursing perspective and using Hodges' model the 'individual processes' would include data gathering, patient assessment, liaison with relatives and colleagues and reflection to integrate information. Evidence-based sources will also be involved depending on the reason for referral, the patients (relatives) account, and the status of the diagnosis. Information technology input will be through the electronic health record that should also provide a history of previous episodes of care and the conclusions reached.

Within Hodges' model below I have added socio-technical and governance. Perhaps, as a systematic scoping review and applied to a specific healthcare profession there is less emphasis on the 'political' dimensions of decision making (management, policy, rules, reporting, targets). Equally from a nursing perspective there is the 'data cleaning' within the research process but then also nurses, and students in particular not being negatively impacted by comments about a forthcoming clinical placement, or a patient / client who has been referred (or referred) to the service / team.

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

individual as subject of mental health Dx

Individual knowledge and experience
Learning and decision-making styles and bias
(positive and negative?)
Feedback from Collective Intelligence?

individual as subject of physical Dx

Individual Input
Group Input

Information Technology

Collaborative working
Clinical Teams

Level of SOCIO-technical
Studies were:
 individual or group process
several a combination.


My source:

Radcliffe, K., Lyson, H. C., Barr-Walker, J., & Sarkar, U. (2019). Collective intelligence in medical decision-making: A systematic scoping review. BMC Medical Informatics and Decision Making, 19(1), 158. https://doi.org/10.1186/s12911-019-0882-0

Monday, August 12, 2019

2019 Conley Art of Medicine Contest c/o AMA Journal of Ethics


The AMA Journal of Ethics with support from the John Conley Foundation for Ethics and Philosophy sponsors an Art of Medicine contest for works in visual media that explore ethical dimensions of health or health care.

Visual media entries will be judged on ethical interest and importance of the content, aesthetic appeal, and its capacity to visually augment content in forthcoming issues of the AMA Journal of Ethics. Artist of winning entry is usually contacted within six weeks of the submission deadline. The winning artist will receive a $5,000 prize.

Please visit here for more detailed information about contest rules.

Eligibility Requirements

Currently enrolled US medical students (MD or DO), resident physicians, or fellows are eligible to submit entries. Entries must not have been previously published in print or electronic format and must not have been submitted to any other publication.

Format Requirements

Entries must include a single contributor’s name, address, telephone number, e-mail address, medical school (and year in medical school) or specialty training program (and year in training program) on the cover page only. If a contributor’s contact information changes, it is the contributor’s responsibility to provide updated contact information.

Graphics (cartoon panels, drawings, paintings, for example) must be in jpg format with a file size limit of 32MB so that it might be easily sized to fit per our production design needs. If an image will lose clarity or readability due to resizing, it might be featured as a link to open in a new window on the journal site.

Within each submission, each entry must include a title, media used to create the art object, and brief (no longer than 50 words) summary description that clarifies each entry’s connections to ethics. For example, for a 5-part series of video shorts or still photographs on patient-physician relationships, the series would need a summary and each video short or photograph would need a title.

Entries must contain only de-identified information about patients, patients’ loved ones, or colleagues. Representations of all persons must be anonymized. Artists retain copyright of their original work, but will grant permission for the work to be published in the AMA Journal of Ethics; this permission must be given by signature for unrestricted use in all versions of the AMA Journal of Ethics.

Submission Requirements

Entries must be submitted to our online system. The submission must include the cover page. All materials must be submitted by 5 PM central time on 25 October 2019, as time-stamped when received by our online submission system. Contributors who have waited even until 4:55 PM, for example, to submit materials have occasionally been disappointed, due to transmission delays, so please plan accordingly.

Saturday, August 10, 2019

Threshold Concepts: Reflection on chaos, complexity and AI

Here are the reflections on the photograph posted in June following the Conference on Threshold Concepts:

Chaos can occur in any one ... or all of the four domains of Hodges' model. The same applies to order.


This is a characteristic of chaos and chaotic systems.

Chaos can arise at any time: in the here and now, being sown now for the future (climate change?), or springing from the past, as in pleasurable, or traumatic memories.

While the Lorenz attractor and other graphical examples are grounded in mathematics and science, in #h2cm we need to imagine the butterfly diagram extended across and simultaneously at work across the models four domains.

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

Even in instances of riot and anarchy there will be pockets of 'order', but would you would want to take your chance of finding one? Amid talk of being in the wrong place, at wrong time; to what extent is this dependent upon who we associate with socially? Or, what we believe is the political course we might, should, will, must follow?

The context of Prof. Land's slide is learning and decision making. As a 'political' matter when chaos occurs, how is it manifested in disintegration? Can we hear the 'gears grind'? What exactly goes awry? Is it the processes as in the timing, leadership and with it responsibility?

The slide is powerful in giving support, to clinical decision-making as a context in which complex decision making is very common and simultaneously encompasses political, rationale and judgemental (ethical) forms of decision making.

Hodges' model can also facilitate recognition of differentiation between relational chaos and the explicit state of decision-making. For example, a healthcare practitioner and client/patient/carer may have achieved empathy and rapport, but the complex demands of the clinical decision still presents a great deal of uncertainty. Alternately in instances when the relationship is being forged then the communications: verbal and non-verbal (and a function of the clinical team) can be a confounding factor if not negotiated professionally (and in socially acceptable terms by members of the public). Another useful perspective is Personal and Public Involvement (PPI) at what point is this achieved? What are the thresholds in the public's learning, as they engage and are engaged if they are not to label the initiative as a checkbox exercise? Again Hodges' model can help us to reflect upon the scope and complexity of such situations.

AI, artificial intelligence was mentioned (I'm sure?) in the presentation and the benefits of AI in healthcare are already being realised. This is tempered with the requirement for AI systems to be able to explain their 'reasoning', rather than this be taken at face value. As AI takes on tasks that include initial automated screening of job applications that include videos then another dimension of learning is presented to students.

Health and justice is by default complex. Consider, the task of being seen by society that justice is duly served and doing so with a duty of care and welfare of the prisoners. To this, we can add the aspiration of custody being rehabilitative. For a prisoner, even on remand, there will be times when health needs and patiency must be recognised. When a long-term prisoner becomes chronically ill, this can present a major challenge to law-makers, prisoners, their families, the healthcare team and society.

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

Identity (use of name, touch ...)
Beliefs, Personal values
 Safety (personal) Thresholds
Trigger warning
Critical - critique 
not taking it personally

[Space] - physical &
degrees of freedom in decision making
Quantitative Research

Qualitative Research

Patient : Healthcare practitioner
decision making
Critical - agreeing to disagree

Schism - 'distance'

Consensus (bridge building)
 Autonomy (in decision making)
Administration / Bureaucracy
Anti- 'X' movements
Riot and anarchy
safety (POLICY)
Critical - political

*While placed within the sciences domain, 'rationale' can be evidenced physically, psychologically,  politically and socially.  It is this that forces us to acknowledge the several edges of chaos.


(Original image)

Friday, August 09, 2019

Targeting poverty (in Hodges' model) c/o The Economist

"Indian politicians are promising more cash for the poor. They should be less selective. "

[ by the quarter - make progress ...? ]

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

"Targeting welfare is costly and difficult in a country like India.

If it looks for signs such as straw roofs, it will almost certainly miss many poor people, especially in the cities.

How is the state supposed to identify the poorest 50m households in a country where income and spending are so hard to track?

The political economy of targeted schemes is also tricky. In countries with minimal welfare states, schemes with few beneficiaries also have few supporters, and therefore risk being quietly wound down or diminished by inflation. And any formula used to target the bottom 20% is likely to be so opaque that people will never know whether they should have been included or not, so cannot fight for their entitlements."

"Two years ago a government report suggested a bold new approach. Instead of a universal basic income - an idea doing the rounds in rich countries - create a nearly universal scheme from which you exclude the richest quarter of the population."

Source: Leaders. Welfare in India: The beauty of breadth. The Economist, April 6, 2019, p.14.
Print edition.

Wednesday, August 07, 2019

One Hundred and Eleven [vertebrae]

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

111 + Self-Care = Sustainable Health Care System ?

Monday, August 05, 2019

VOGUE: As they say - don't judge a ''book' just by its cover ...

... there is a resource to help you really reflect!

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

"The 16th spot on the cover will appear
 in print as a silver reflective mirror, to
 show how you, the reader, are part of 
 this extraordinary moment in time –
 and to encourage you to use your own
 platform to bring change."


Vogue, September cover


*Whatever your chosen career at this 
point in time and throughout your 
lifelong aspirations and learning.
Best wishes!

Cover image source: Vogue.

Sunday, August 04, 2019

Pandemic Bonds: Beware perverse incentives and instruments?

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

Number of Countries
Number of fatalities
Instruments: Legal, Science, Social, Policy, Financial ... ?

"On Wednesday [24 July], the World bank said it  would give $300m in grants and loans to DRC to step up its aid response.

But funding connected to the World Bank's pandemic bonds, issued in 2017 have been less forthcoming. One relatively small slice - the so-called "cash" element - has delivered $31.4m to help with the crisis."

Ebola's latest resurgence in central Africa has led to more than 1,700 fatalities. But for the insurance element of the bonds to pay out, the disease must cross an international border and there must be at least 20 fatalities in the second country.

The total possible insurance payout for Ebola is $150m and comes in three tranches: when 250, 750 and 2,500 people have died across at least two countries, $45m, $45m and $60m, respectively, will be disbursed."

Pandemic Bonds

World Bank:
Pandemic Emergency Financing Facility

DRC - Rwanda border

My source: Asgari, N. (2019) World Bank pandemic bonds spark Ebola anger, FT Weekend, 27-28 July, p.17.

Photograph - adapted from original by The Independent.

Saturday, August 03, 2019

Seeking Care & Global Cultural Neutrality in White Houses(?)

The email concerned a book
- | White Houses | -
 and posed a question.

Needless to say it caught my attention ...

Is White a Statement or a Neutral Surface for Expression?

This is a question I ask myself, but in respect of Hodges' model.

To what extent is Hodges' model neutral across cultures?

Remove the green, blue and red colours I adopted for the care domains  and what you have is a blank sheet; an empty conceptual space.

Is it empty? 

Very quickly it can become filled with what the person, patient, client, group ... brings with them.

Hodges' model is a stage. Several stages.

It is a theater.

It is a challenge for the performer, as they take their turn. As they navigate the space, they seek to ensure, assure, obtain feedback that the other - listener(s) are with them; whether in agreement or not.
Hodges' model is an arena for personal, group reflection, debate, argument(ation) or as described these days - co-production.

How suitable is #h2cm as a tool to support global health objectives, such as, the Social Development Goals and the Social Determinants of Health (and their ongoing development)? For me, Hodges' model is not just a neutral surface, it is a neutral substrate for the many forms of knowledge needed to solve the problems of the 21st Century.

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

My source: Thames & Hudson

Later in the summer - autumn I might post another photo in memory of my father and a holiday ...

Friday, August 02, 2019

Int. Handbook of Health Literacy - Ed. Okon, et al. c/o HIFA

International Handbook of Health Literacy

Dear HIFA colleagues*,

I was interested to see the publication of this new book International Handbook of Health Literacy, edited by Orkan Okan and colleagues.

Kudos to the editors and authors, who have made the content freely available here:


The early pages note: 'Besides the ongoing and tremendous public health efforts addressing health literacy in Europe, North America and the Australasian region, there is only little to no work still in Africa, very little in the Middle East, India and South America, and also very little in Russia and the Slavic countries in Europe.' Nevertheless, 'health literacy has been placed high on the agenda in the WHO Southeast Asia Region via the introduction of a health literacy toolkit for low- and middle-income countries to help communities to develop their own solutions'.

There is a chapter on 'A stated preference discrete choice health literacy intervention framework for the control of non-communicable diseases (NCDs) in Africa' by Kenneth Yongabi Anchang and Theckla Kwangsa Mbunwe.Selected extracts below:

The function of health literacy in ensuring a healthy condition in individuals and communities is especially relevant in Africa, which is plagued with high endemic diseases, and in settings in which healthcare resources and infrastructure are, for the most part, limited (O’Sullivan et al, 2003; Remais et al, 2012).

Current health promotion interventions in current use in Cameroon and Africa at large are inadequate as they are too exo-centric in style, language and construction – a health literacy intervention culled from a very exo-centric set-up and tailored for the European context, for instance, may not be transferable to Africa.

Health promotion exercises in Africa are currently too linear in application. Linearity here means providing a solution to a certain problem without taking into account the contextual barriers of its wider implementation, which may be entirely different from what the researcher or facilitator wants to provide, as well as its perceived urgency and necessity.

Individuals in Africa for the most part grow up either with no health knowledge, little health notion or wrong health information that has been passed on from their parents. Some health information is misconstrued and parcelled into local beliefs systems and superstitions, thus making it difficult to dispel over time and space.

In a community whose priority is potable water, a health literacy intervention on curbing diabetes and cancer may not be quickly be accepted and sustain. This urgent need may mask the need for a literacy programme that addresses hypertension or cancer. To this effect, a joint intervention approach of providing potable water and then educating people on hypertension and cancer is the way to go.

Interventions for health literacy and promotion must always be built first on the ‘available local health knowledge’ that might, for the most part, differ from what researchers and health literacy providers would consider as evidence or knowledge.

Best wishes, Neil

Some reflections:

This is a very welcome text and step for health literacy. Even in a tome of 766 pages (I have not read it all) it is difficult to address all themes of significance within the field; and in turn please everyone. That is the case here.

It's not that I've got an axe to grind: I've two axes - in #h2cm.

How far is it between lifespan and life course on one-hand; and health career and life chances on the other? Especially when these are examined critically in the context of the sustainable development goals and the social determinants of health.

Chapter 42
Salutogenesis and health literacy: The health promotion simplex!
Luis Saboga-Nunes, Uwe H. Bittlingmayer and Orkan Okan
When examining the scientific discourse around health literacy, we are surprised to see that while scholars have been extensively discussing the ‘literacy’ component of the composed term ‘health literacy’, discussion of the ‘health’ element is hardly to be found. ... Today, broad literacy concepts addressing functional, interactive and critical literacy are added to the health literacy discourse, giving way to multiliteracies and social literacies to merge with health literacy (see Chapters 14, 18, 36 and 39, this volume). This was not only the impetus for multiple research strains that broadened the theoretical and conceptual discussion, but also facilitated the uptake of health literacy by various research disciplines, such as healthcare, medicine, public health, education, psychology or sociology (p.649).
The need to rethink, and maybe also construct, the health component of the health literacy concept and its social representation needs to consider that health can be understood and approached in different ways (p.650).

As a volume of recent developments in health literacy, that includes an Integrative Model of eHealth Use (p.277, 278) there is (imho) a need for a generic conceptual framework upon which to base the local, global and glocal theory, practice, management and policy of health literacy.  Not only that but how health literacy relates to other forms of literacy. If not you are more likely - conceptually bound - to loose your footing socio-technically. As Saboga-Nunes et al. note, a normative framework is needed (p.651). Negotiating forms of literacy invariably entails questions about design and in chapter 39 avatars extends this to ethics. Hodges' model can readily encompass and incorporate simplicity, continua, complexity: health and literacy.

There is much more here in this great resource, to which I will return e.g. Chapter 43, Figure 43.2 Research traditions.

*My source.

Thursday, August 01, 2019

The 'transdisciplinary' (and other forms - in Hodges' model?)

A transdisciplinary model of practice

"This model is different from the multidisciplinary and the interdisciplinary models, where occupational power, status and professional recognition are key issues.
‘Representatives of different disciplines are encouraged to transcend their separate conceptual, theoretical and methodological orientations in order to develop a shared approach to ... building a common conceptual framework’ (p.1351). Rosenfield.
The shared philosophical perspective that is created by all disciplines and public representatives enables practitioners to provide integrated services. All team members, including consumers, parents and community members, are involved in discussion, consensus building, decision making and implementation of the plan or the programme. Team members work together to explore different theories, conceptual frameworks, concepts or approaches that might be in the best interest of the patient, family and the community. This sharing of knowledge enables team members to learn from one another. Boundaries between disciplines are loosened, and overlap between services is recognized and incorporated into the plan, so that patients and families benefit from using similar but different resources in increasingly more practical and more meaningful ways." (p.1351).

Rosenfield, P.L. (1992) The potential of transdisciplinary research for sustaining and extending linkages between the health and social sciences. Soc Sci Med. Dec;35(11): 1343-57.

cited in:
Anderson, G.W., Monsen, R.B., Rorty, M. V. (2000) Nursing and Genetics: a feminist critique moves us towards transdisciplinary teams, Nursing Ethics, vol. 7, 3: pp. 191-204.

Tuesday, July 30, 2019

Book: In Praise of Walking - The new science of how we walk and why it’s good for us

Count: the number of steps...?

You don't have to count - just walk ...

individual - self
humanistic ----------------------------------------------- mechanistic
group- population
"The sea squirt starts life boring, and gets more so, but along the way it does one thing that is very interesting indeed. In its larval stage this creature swims around the rock pool, its tail propelling it much like a tadpole's. Its talents at this time are not impressive, being  limited largely to staying upright and hiding from predators. At least it moves, though. When adulthood approaches that changes. It sticks itself to a rock, where it will stay fixed for the rest of its life. And the first thing it does upon finding a suitable site, the one interesting act in its life? It consumes its brain." Whipple, 2019.
In Praise of Walking

As you walk, let Hodges' model provide a cognitive map for your reflections ...

My source (several)
Whipple, T. (2019) Walking - our super power, Saturday Review, The Times, p.14.