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

Friday, February 15, 2019

c/o BMJ Open: Mapping of modifiable barriers and facilitators of medication adherence in bipolar disorder to the Theoretical Domains Framework

Finding this item on twitter c/o @Stuart__Maddock its interest and relevance to me is explicit in the title, but also as a protocol, with more to follow. The range and application of the domains listed and the four themes also have significance here. The abstract includes:

"This systematic review aims to identify modifiable barriers and facilitators (determinants) of medication adherence in bipolar disorder. We also plan to report determinants of medication adherence from perspectives of patients, carers, healthcare professionals and other third parties. A unique feature of this systematic review in the context of mental health is the use of the Theoretical Domains Framework (TDF) to organise the literature identified determinants of medication adherence."

Of course there are many potential overlaps. For example, knowledge; the decision processes - to what extent are they collaborative - studies with patient involvement, also concerned with concordance not just adherence? Are they supported through the use of digital technology? Goals can be multiple as in person - patient centred, to support carers, policy development or an assessment instrument. That 'emotion' is all too readily experienced by families too in the event of relapse.

humanistic ----------------------------------------------- mechanistic
(1) Knowledge

(4) Memory, Attention and ...
(7) Beliefs about Capabilities,
(8) Belief about Consequences
(9) Optimism, (10) Intentions
(11) Goals, (12) Emotion

... Decision Processes (4)

(13) [Physical] Environmental Context and Resources

(2) Skills
(3) Social Influences

(5) Behavioural Regulation
(6) Professional/Social Role and Identity
(13) [Social] Environmental Context and Resources
(14) [Social] Reinforcement

(13) [Political] Environmental Context and Resources

(14) [Political] Reinforcement. 

"Within Nvivo V.12, we will create four themes in line with the aim of this study" ...

I have mapped these themes to Hodges' model as follows:

humanistic ----------------------------------------------- mechanistic

Patient Perspective

HealthCare Professional Perspective

Carers Perspective

Others Perspectives

These themes reflect to some degree the original website (1998-2015) introductory pages for potential users (four audiences) of Hodges' model per each care domain, as follows:

INTRA- INTERPERSONAL: Patients, Service users, Clients
SCIENCES: Students, Lecturers, Health care professionals, Researchers, Social workers ...
SOCIOLOGY: Carers, the Public, Communities
POLITICAL: Managers, Policy makers, Law makers ..

See also: Elizabeth Mamo

Tuesday, February 12, 2019

Saturday, February 09, 2019

Book review: iv Critical Mental Health Nursing: observations from the inside

Following on from Part i, Part ii and Part iii.

I'll try and condense things in this review-post.

The book has a global reach and is Antipodean in chapter 4 with Darren Mill's ethnographic dialogue of a MH Crisis Team in New Zealand. The account, while fictional is based on authentic events and is still quite 'socially visceral'. This is achieved by interspersing the text with statistics on demographics, ethnicity, culture, suicide rates and government policy. Additionally the author provides reflective thoughts on the telephone dialogue FROM: the office; TO: standing at a front door (and wading in water).

Resort to the police and use of the Mental Health Act (MHA), made me reflect about westernised MH services and the export of this model to developing nations; while acknowledging that New Zealand is 'developed' of course. Despite this, as Mills shows, there are profound health care and education concerns for indigenous peoples in Oceania. As Universal Health Care and the SDGs become key drivers (added to general economic improvements, rising middle-classes...) it appears many developing (Commonwealth) nations prefer the institutional care that Westernised medicine is still trying to disassemble, change, or distil into the community (see p.779 in Persaud, et al. (2018)).

While we quite rightly (crucially) talk about the choices for patients - the public; we might ask what choices are there for services? In instances of challenging behaviour within an institution (hospital - residential, nursing home...) we seek to (alter the environment) quieten, distract, divert, de-escalate, comfort... Perhaps, the avenues, the choices that mh services have - is a measure of their person-centredness, integration, modernity? These choices then have a direct bearing on individual practitioners values (p.89 as quite nicely follows...).

Critical Mental Health Nursing
Values are key in Felton and Stacey, The Doctor-Nurse Game in acute mental health care. Addressing values, commonalities and how they are defined, held, shared should better reflect the ideals and pragmatics that 'progressive mental health nursing (and policy) demands. This would obviously reduce the contention (violence, injustice, coercion...) and very need for this book. While gut bacteria have been implicated in mental illnesses and may number in the many millions, no amount of them will account for the contested state of mental health. Not until the issues in this book are more effectively reconciled and resolved then as Felton and Stacey state mh nursing work will remain a form of 'dirty work' (p.99). Felton and Stacey provide a practitioner focus on values-based practice. Value and values permeate the literature as I have noticed over several years. The distance that Felton and Stacey identify for academia from the 'dirty work' (p.103) is an experienced reality for community nurses. Many, including myself, are aware of  a wish to 'step back' as 'your' patient becomes an in-patient. Recognising the need to maintain a therapeutic relationship you don't want to be seen as an 'agent' of this particular change (not all thresholds are conceptual). I have negotiated this on many occasions and not always successfully which I wholly respect.

Chapter 6 Gary Sidley sets a critical stall - stance in 'Colluding with prejudice? MHN and the MH Act'. A brief history is provided; Sidley discusses the MHA as being legalised discrimination, Community Treatment Orders, Advance decisions and socio-political considerations in two dubious contructs: 'mental disorder' and the 'estimation of risk' (pp.111-113). He seeks alternatives to the MHA, questions the silence of CMHNs (p.115) and offers four explanations (pp.116-117). Another factor, and not an excuse, may be the loss of beds over the past 20 years and the distance between community services and their in-patient centers.

On page 117 and explanation four regards low self-esteem and high burnout among psychiatric nurses I wrote in the margin "DATA on teams. Meetings for MHA not about". Here in the NW England there used to be (late 1980s - 1990s) evening meetings for Community Mental Psychiatric Nurses. There is less local professional cohesion these days, if any? Admittedly, it takes leadership to drive such groups. While there is data for the MHA 2017-2018; individual practitioners and teams as a whole (often?) lack the information to manage individual caseloads in a statistical manner, or as a team (and adopt a default research stance).

Sidley is optimistic (p.119) citing a survey and report by the Mental Health Alliance (2017) and the conclusion that the MHA "is not fit for purpose". The optimism arises from political commentaries that suggest an impetus and opportunity that can bring change. Sidley asks the reader if mh nurses should become political activists. (In the late 1970s-1980s you wore a 'NUPE' or 'COHSE' badge, the RCN was not considered a 'Union' back then, and mental health hospitals were far more 'industrial relations focussed' than the Royal Infirmaries and General Hospitals.) Is there a place for conscientious objection in respect to the MHA, sending a powerful message and signal for an urgent need for reform (p.118)? Is there an irony in this (an inter - h2cm - domain), a twist on parity of esteem? On twitter I have noticed The Power, Threat, Meaning Framework provoking much debate (a future post?). This is another tool for change proposes Sidley. The chapters included here highlights again the importance of a book, and well referenced too; which I would encourage students, practitioners, managers and others to read.

Critical Values Based Practice Network

Persaud, A. et al. (2018) Geopolitical factors and mental health I. International Journal of Social Psychiatry, 64(8) 778–785. DOI: 10.1177/0020764018808548

Friday, February 08, 2019

c/o The King's Fund: Making sense of integrated care systems, integrated care partnerships and accountable care organisations in the NHS in England

When I see a 'model' I ask myself; what does this mean in itself? What is its purpose? I also (invariably) ask how does it relate to, or how might it support the theory and application that might underpin h2cm?

In February 2018 The King's Fund posted this item on integrated care systems. It wasn't just the 2x2 figure that caught my eye, but the axes and the additional amber tab (figure 1). Pondering for a time I have transposed this to Hodges' model below figure 1. Beneath that, I've provided an explanation for the altered schematic; recognising that as with h2cm such models are idealised representations.

c/o The King's Fund

humanistic ----------------------------------------------- mechanistic
Individual care management

Care for patients presenting with illness or for those at high risk of requiring care services

Population Health (systems)

Improving health outcomes across whole populations including the distribution of health outcomes

[Improving population health outcomes requires multiple interventions across systems]

'Making every contact count'

Active health promotion when individuals come into contact with health and care services

Integrated care models

Co-ordination of care services for defined groups of people (eg. older people and those with complex needs)

Individual care management has been changed from care services and individuals to this domain, which conceptually preserves the original placement. In h2cm as can be seen the interpersonal domain combines the individual and humanistic. In the 4Ps this domain also includes 'purpose'. Whenever possible it here (individual motivation) that self-care and self-efficacy and staying as well as possible relies on the patient's awareness and education about their condition and level of health literacy. There is recognition now that children need some awareness of mental health issues and the law needs to protect what images and content youngsters are exposed to on social media. So, ultimately 'how I manage myself' has a major bearing on the 'whole care management enterprise.' The focus on 'high risk' also denotes a need for an assessment and one that is part of the move to parity of esteem in respect of physical and mental health.

I have shifted Population Health (systems)from population to this (physical) individual domain, on the basis that our research, as in, quantitative and qualitative, needs to be synthesized and then ultimately generalised - across populations. While complex systems cannot be taken apart it is from the sciences (including social sciences) that evidence-based practice flows. There should be a feedback loop here, research that also takes into account the multiple interventions across systems (the amber tab in figure 1) and the outcomes achieved.

The King's Fund's figure 1 stands as it is of course, but I have 'moved' Integrated care models most radically. If there is no organisation, rules, order, policy, procedures ... then things will NOT happen (as they should). Agreement is also needed on definitions for reasons of standards, measures and accountability. Such matters are political (even if ignored - kicked in the long-grass). For services that are evidence-based (as just mentioned in SCIENCES) we need when possible for health and social care policies to also be evidence-based (for reasons of efficiency, equity, effectiveness and equality). While we cannot 'break' complex systems we can break models; 'health care systems' need to break ("be broken whilst still in flight") in order to be transformed for the 21st century.

Making every contact count I have placed in the h2cm's Sociology domain. To me this initiative remains with care services, but I have switched this from individual to group-population within h2cm. Health care education places constant emphasis (research, CPD, mandatory training) upon interpersonal - communication skills and this is where clinical and social care interactions and interactions ultimately count. It is here that trust, the 6Cs, unconditional positive regard ... are 'counted' in qualitative terms. If the psychological represents the theory of psych-social intervention, it is in the social outcomes and benefits were the practice is (truly) delivered. It is also here that partnerships are forged and social capital found.

In social care as an example, the integrated care model should politically permit - allow for a sufficiently skilled and remunerated work-force (socially valued?) with sufficient time to ensure that every contact really does count.


Forty years in the NHS suggests that when ever 'integrated care' is being written and even spoken about, then the context should be indicated at the same time; so at least - integrated care1-5 as above?

'integrated' as in -
  • philosophy (ethics, morality, values)
  • spiritual (values) (and part-whole of 1-5)
  • political - policy, government funding
  • economically - commissioning (models of care, sustainability)
  • management
  • care delivery
  • team organisation
  • community involvement
  • patient involvement
  • health literacy, health promoting

Accessibility: apologies that there is no equivalent text to figure 1.

My source: https://twitter.com/TheKingsFund/status/1093556280248147969

Tuesday, February 05, 2019

Book review: iii Critical Mental Health Nursing: observations from the inside

Following on from Part i and Part ii.

Alec Grant's chapter 2 presents a 'critical meta-autoethnographic performance'. The chapter uses a dialogue approach, as with chapters 3,4 and 9. While not needed this does break up the prose format for the reader. For a 'nursing' book it is good that Grant puts the initial accent on the future and the classroom. There's a conversation with a Deputy Head on establishing debating societies (p.34), another highlights how skills in reflection, critical thinking and critique are never complete at undergraduate level, but applied through narrative inquiry and critical autoethnography at masters research level (p.40).

The first classroom 'chat' begins with a question: What is the student's "understanding of the following social psychological phenomena: confirmation bias, fundamental attribution error and actor-observer effect?" (p.30).

Critical Mental Health Nursing
On fundamental attribution error, taking a couple of patients to Goodison Park and while the final score eludes me I can remember the change in the patient's behaviour while 'outside' away from the ward. Likewise, going to a nearby pub to 'find' a patient, his speech, disposition and humour were as liberated as his taste buds and that wasn't just the 'alcohol talking'. On the actor-observer effect, judgemental terms would often presage the arrival of; if not an admission, but a re-admission. Even then I would take cognizance of what was said, but also derive my own conclusion. I discuss 'attention seeking' and manipulative (p.31) and other pejorative terms with students. Also explained is our then Director of Nurse Education, who stated that "All behaviour is significant". Grant reflects on 'narrative entrapment' and how things are in community mh services, as surely that is better? The quality of referrals is raised. I've always thought that referrals, or more accurately, reasons for referral need to be qualified. That said, this has improved over the past 10-15 years, but there are still examples were the 'problem' and the level of information provided is missed / lacking.

Throughout the text, there is much for students to learn and reflect upon. Grant is Socratic in approach, creates discomfort and signposts how learners can become students for change and change agents. There are insights on 'ideology',  Žižek and efforts to find a position in the world that is 'ideologically neutral' (p.37). Even now, I continue to see h2cm as, if not, ideologically neutral [impossible], then it is 'ideology' stripped back to absolute basics; a fundamental stucuture that can represent and encompass a[ny] situation. That can include, as Grant notes, time, place, people, events, institutions, culture and professional groups.

Grant's critique of the Tidal model is brief (p.37), but the way to which the Tidal model is challenged within the average busy acute ward, can be extended if the health AND justice 'care' context is considered. While there are only two references to Hodges' model within health justice, I am sure there are potentially many more. Without change, Grant suggests that mhn is "condemned to be the constant administrative and social policing arm of institutional psychiatry." (p.37).

A section on reader - response theory takes us - in a sense - back to where we started. The final dialogue may be 'heavy' for some (me too?) on the neoliberal agenda and its impact upon education - professionally, institutionally, mental health nurse education and curricula. Universities as institutions for learning and learning institutions have been called into question (safe spaces, freedom of speech, value for money, quality...), as by Grant also:
"With regards to mental health nursing, a technical rational training, as opposed to education curricula, fails to adequately address the skilled, multi-contextual knowledge and skills needed by students to help them engage in the unruly and complex identities, relationships, and life and treatment environments of contemporary mental health service users (Grant, 2015c)." (pp.41-42).
"... we put forward the argument that such engagement requires an explicit, un-apologetic educational curriculum." (p.42).
 Grant calls for 'professional artistry' through the literature, which -
"... requires increasing levels of critically reflexive organisational and political awareness. This is because, in all of its aspects, mental health nursing practice is political, historically contingent and socially and environmentally contextual." (p.42).
Finally (here at least), Grant references Alvesson and Spicer's (2012) "functional stupidity theory of organisations"

(In the margin - my pencil notes: Is it really about who has the keys?)

The functional stupidity theory of organisations argues that such organisations have, "a cognitively- and affectively-informed unwillingness or inability to employ reflexivity, justification and substantive reasoning in work organisations." (p.43). Grant expands on each, but of substantive reasoning:
".. constitutes the act of engaging thinking as broadly as possible in relation to professional practice and related work problems." (p.43).
Mental health nurse education, according to Grant exhibits functional stupidity.  (p.44). Oh! I wince at the sound. Finger nails scraping all the way down the ivory of the tower.

As a critique of this and other reviews on W2tQ will no doubt show, my quotes are quite obviously  selective. Precarity has also become obvious over the past decade, as austerity has bitten and even now continues to 'chew'. Grant's references show his work in this area. As many people, academics and practitioners (across all professions including social work and the chapter's author) reach retirement, it will be interesting to see (to say the least) if precarity also applies to:
  • mhn
  • the mhn education system
  • the reasons and values that students bring to the profession
Paradoxically, will this loss of experience in academia, practitioner and management, bring the positive change that this book calls for?

Just two chapters and buy, buy...

More (still) to follow and apologies for the unconventional review...

Book: The Age of Surveillance Capitalism - The Fight for the Future at the New Frontier of Power

humanistic ----------------------------------------------- mechanistic

The Age of Surveillance Capitalism

My source: The Times, January 19th, 2019.

Cover image: http://www.shoshanazuboff.com/

Sunday, February 03, 2019

Theory on Demand #29 Good Data


"Data can have power in numbers. Not only in the literal sense, rather, just as repeat - ability is important, so aggregation and meta-analysis of repeated and comparable studies acts to reduce the uncertainty of individual studies. Cochrane reviews in medical research carry a good deal of weight for this reason and are considered 'gold standard'.33 These reviews reduce the influence of individual companies or vested interests, and lead to more informed health policy." (p.48).
"Those questions underpin a consideration of contemporary genomic initiatives, particularly those that are marketed as 'recreational genomics', and gene patents such as those held by Myriad Inc. More broadly they underpin thought about population-scale health data initiatives such as the UK care.data program that, as discussed below, encountered fundamental difficulties because bureaucratic indifference to consent eroded its perceived legitimacy."54 (p.144).

See other TOD titles c/o The Institute of Network Cultures (INC)

humanistic ----------------------------------------------- mechanistic

Something you know


personal ethics

('good' data = 'here'?)


Something you are
Something you have 

(proximity = 'are' + 'have')?

'open data index'

social activism
social assets
social capital
social data
social ends
social (collective) ethics
social good
social justice
social media(?)
social science

data: "power in numbers"


bureaucratic ethics

My source: https://twitter.com/ArnaldoPellini/status/1089196464310501377

Saturday, February 02, 2019

Book review: ii Critical Mental Health Nursing: observations from the inside

Following on from Part i

In fairly recent studies at Lancaster University (2014-2016) autoethnography was notable by its presence. Given the importance of reflection in mental health theory and practice and the self-reflective approach of autoethnography and its qualitative, objective - subjective focus it is not surprising that several chapters adopt autoethnography. From Wikipedia:

Autoethnography differs from ethnography, a social research method employed by anthropologists and sociologists, in that autoethnography embraces and foregrounds the researcher's subjectivity rather than attempting to limit it, as in empirical research. While ethnography tends to be understood as a qualitative method in the social sciences that describes human social phenomena based on fieldwork, autoethnographers are themselves the primary participant/subject of the research in the process of writing personal stories and narratives. Autoethnography "as a form of ethnography," Ellis (2004) writes, is "part auto or self and part ethno or culture" (p. 31) and "something different from both of them, greater than its parts" (p. 32). In other words, as Ellingson and Ellis (2008) put it, "whether we call a work an autoethnography or an ethnography depends as much on the claims made by authors as anything else" (p. 449). https://en.wikipedia.org/wiki/Autoethnography
Gadsby's chapter 1 "Nursing violence, nursing violence" starts in this research vein. The title is quite an affront to many nurses. These two words do not mix, violence an abomination, antithetical and counter to all that 'nursing' should represent. This is in part why 'care scandals' are so shocking given the vulnerability of those affected and impacted for years to come. Gadsby points straight to the challenge:
"I do not like to say, as  some critics do, that reforms of mental health nursing is impossible; I think of good moments and good colleagues and feel it betrays them. I worry that this chapter will feel that way too." p.14.
There no better learning than when your assumptions are turned on their head; you are forced and can see for that instant the other side of the coin, even if, like an optical illusion it snaps-back. Gadsby presents three conversations. Inevitably in conversations there is the verbatim transcript (as if recorded audio-video), then there is our account of what was said and then what is recorded on paper or in the electronic record. Jonathan Gadsby points out that he was selective in his accounts and this is a prime judgement for mental health nurses. What is pertinent is looking at this from the patient's* perspective. The complexity of his (John) mind was likely to be interpreted as illness, and this presages coercion and loss of his future.
"He took care of their (mhn's) mental state. I have come to believe that this is common; our simplistic stories leave our service users having to channel their real lives into fairly useless false binaries and sanitised, dishonest versions of their actual experiences, in order to gain or retain any power. p.15.
https://www.pccs-books.co.uk/products/critical-mental-health-nursing-observations-from-the-insideRereading the section for this review on 'John' I was surprised it was so short. Reading this was like revisiting several clients of old. 'Old' bears specific mention as some of the situations used in the book, are quite dated - John refers back to 2004. The lessons and insights are still salutary. In exploring 'violence' the chapter starts by explaining debt violence. It is 'social inclusion' in practice (and an appeal to and for justice?) to see this, considering austerity and campaigns stressing the links (ties) between financial vulnerability and mental illness. On 'nursing violence', Gadsby discusses three areas: a few bad apples, 'genre violence' and the world is violent.

My ward experience as a charge nurse was brief 1982-1985, so I have been removed from the 'frontline' of mh services. Without being ageist I've been twice-removed in working with older adults. Since becoming a Community Psychiatric Nurse in 1985 if the narrative had been wholly positive: the funding, policy, education ... what would the experience for patients, staff and carers? If mhn could ask itself the miracle question of solution focussed therapy, what would our history, present, future be like?

Some of Gadsby's points are shocking and reveal the experiential fact of the few bad apples. There is an overlap here with Nikki Marfleet, a speaker at this past week's Health and Justice Summit. @TheLRH stressed the need for assuring that both good and difficult conversations with staff take place. As a student nurse and newly qualified nurse you recall wondering who you were to work with next shift: and not just management-wise. It was not necessarily the 'who' you would be working with, as the 'attitude'. This is a fact of life within many occupations, but in mental health the impact can be literally that. Nikki noted that the difficult conversations can be positive as well as challenging behaviours and attitudes as the desired team culture is built. The bottom line though on the tenor of the difficult conversation is can you, do you, really want to keep that bad apple? I have seen situations were the approach was, if continued, provocative and not deescalating. We have all met them, the individuals, who, even after giving them the benefit of doubt, you are left wondering why are you still here (and somewhere quiet you tell them).

The Recovery Star (Triangle updated) saw Gadsby as a life-coach being an early adopter. 'Recovery' features markedly in the book. The figure and description of Smith's work - 'The structural model of genre'. There are practical insights here, especially for new student nurse. As Gadsby writes of, "trying to change the system from within.", I smiled ruefully. I used to feel sympathy, oops sorry! empathy, for the patients on the Long Stay ward [37A] and others. I had a distinct sense that as a new group of students started, the patients rolled their eyes (and not in some oculargyric crisis*) but out of their patience (yes, the patient's patience) being tested to maximum. As the students set-to to change the behaviour pattern of some key individuals (were they viewed as such?). They slept late, smoked too much, might palm - pretend to swallow their medication, they spent too much time on their beds, their personal hygiene was poor. They were certainly 'key' as subjects for our student assessments; yes, me too.

In my reading, Gadsby alludes to the rationale by which people are attracted to mental health nursing (p.22). Perhaps stories have a formative role to play? [At risk of a slight digression] Recently I've been really surprised by the psychological and medical content of TV programmes I was watching from age 10-11. Star Trek's "Dagger of the Mind" for example; UFO with "Sub-Smash" and "The Man Who Came Back" and many others (in contrast to many peers at the time I only saw "One Flew Over the Cuckoo's Nest" in the 80s).

If that is (was) about 'future nurses' Gadbsby refers to Burstow's institutional ethnography, and one "notion of how psychiatry is perpetually on the cusp of a humane scientific breakthrough" (p.23) Critically, this is not Star Trek, but how Burstow explains the violence of the present in terms of time. Gadsby teaches psychiatrists too and this book has lessons for the whole 'multidisciplinary team'. He points out how models of care as we deliberate on 'caring about' versus 'caring for'.

Hodges' model is a 'health career' model, not a model of care, but it can help facilitate all forms of care.

Gadsby and other authors here identify many polarities: care and control, advocacy and correction. In the late 1970s and 1980s we were not just nurses, but 'patient advocate'. The nurse literature and rising profile of human rights called this into question. In mental health though for some formal meetings you may struggle to have an independent advocate present (is that time playing with us again - temporal violence of however many hours, days, months?).

humanistic ----------------------------------------------- mechanistic

The person - individual - self

"proximal experiences"

"over the power horizon"
"distal power"

Gadsby correctly anticipates that this account of experiences, thought and conclusions may be read as damning. The book as whole provokes a real double-bind. The violence is a reality (yes, look at the World, p.25) and so often violence is the news#. So too, is the compassion to effect (constant) change; even as the medication is administered in the sacrifice zones (pp.27-28).

Gadsby writes: "We frequently work within models that fail to make sense of the connections between inner and outer experience, past, present and future..." (p.25).

Yes, don't we just (whether accidentally or not).

Difficult as this is, this text is vital reading for CMHNs, nurse students and a much wider audience.

More to follow - with possible additions# here...

*Seriously, I am grateful to say I have not witnessed this in my 41 year career.

Friday, February 01, 2019

Book: Digital Objects, Digital Subjects: Interdisciplinary Perspectives on Capitalism, Labour and Politics in the Age of Big Data

humanistic ----------------------------------------------- mechanistic

Digital Objects Digital Subjects


Capitalism, Labour, Politics


Cover image: Amazon

Thursday, January 31, 2019

6th Health and Justice Summit: safety with continuity i

Whilst I am using Hodges' model (h2cm) to 
reflect on the 1st day of this event no 
endorsement should be inferred...

My exposure to forensic - prison nursing is trivial in contrast to the emotions, policy, issues, contention and hence importance that just the word 'prison' provokes. This statement can can be summarised in one point that was made this afternoon. That is, how any duty of care to prisoners must be balanced with the public's perception* of what should and should not be done. The word important is a moot one when the the aim is to stress the risk of being forgotten. Prison health is surely in danger of being lost within the Russian doll of mental health. Mental health that was (still is?) also the Cinderella service of health care? I refer to history in celebration since while there was mention of pressure of staff, long shifts, not feeling valued, heightened risk there was no shroud waving. Attending today was refreshing in the expressed passion, pride and enthusiasm that I heard; even while some of slides showing older and newer prison interiors and rooms - cells - were sobering (as they are supposed to be*).

My forensic experience is limited to time as a student nurse, making numbers up, on Ward 17 at Winwick. Visiting a medium secure unit to liaise and 'communicate' about the National Programme for IT and co-writing a paper on the Hodges' model in forensic settings. I have long wondered about the model being used educationally with groups in primary care, looking at stress and vulnerability, resilience, staying well ... and perhaps more selectively with this population. A strength here is the model's use: explicit - explained and shared or used implicitly guiding the 'teacher' or (more properly?) facilitator. We invest in 'life story' interventions for people with dementia. What about the 'life stories' of prisoners? It not the matter of their life story, but their lack of understanding of that story? What tools are there to help make sense of their 'health career' the life chances encountered and experienced in their lives?

The keynotes this morning emphasised the facts and figures of the physical health of prisoners with severe mental illnesses [SMI] and the work of Equally Well. Amid many health problems the focus is upon obesity and smoking cessation.

Dr Alan Cohen from Equally Well, reported on surveys and analysis of national QOF data comparing the prevalence of people with SMI in ten long-term conditions. As per the summit website: “The physical health of those with a severe mental illness is held up as one of the last significant health inequalities. This presentation will explore some of the data that underpins that inequality. This will describe how it can be used to enhance services, through the development of a national learning network. Equally Well.”

There are plans for an evaluation phase of the work and other audits. Dr Cohen almost had me ask a question, with regards to some people having three health problems across least and most deprived populations. How can this be explained?

The second keynote c/o Stephen Watkins confirmed (for me) the history of mental health beds (below) and how ongoing studies and graphs can illustrate processes across prisons. How long do prisoners have to wait for mental health transfer and remission? Diagnoses, across gender, ethnicity and outcomes were also presented.

Stephen Watkins NHS Benchmarking

Stephen Watkins NHS Benchmarking

I will post soon on the workshops I attended. As is often found with satellite sessions the choice is difficult at times.

Tomorrow I must ask someone about 'social care' input. I have had cause to liaise with palliative care and local hospices recently, dementia and cancers. A question concerning a very literal form of 'in-reach' was asked for me. With four people to follow up with tomorrow, great organisation and day 2 to follow it will be a 'breeze' getting out of bed - even if that breeze is chilly...

humanistic ----------------------------------------------- mechanistic

primary care
Society: SOCIAL (care): Family interface ::::::

Prison Health
--------------  INTERFACE -------------
Prison Service

humanistic ----------------------------------------------- mechanistic

personal autonomy

OPEN door
Mechanistic: 'Lock' 'Up'
Ability to step on the grass

Family involement
(What do they know?)

prison experience
in-validates the 'person'
narrows - restrains - autonomy

Reflective exercises: define 'continuity' as per Hodges' model?

What is the bandwidth of autonomy across the domains of Hodges' model?

Contrast the return to society of prisoners and service veterans?

Tuesday, January 29, 2019

"Study in blue" Dictyota dichotoma

humanistic ----------------------------------------------- mechanistic

Anna Atkins (1799-1871) Dictyota dichotoma, in the young state & in fruit,
 from Part XI of Photographs of British Algae:
Cyanotype Impressions 1849-1850 Cyanotype

family tree

Chuang, J. (2019) Study in blue, FT Weekend Magazine, January 5-6th, pp.32-35.

Monday, January 28, 2019

Book review: i Critical Mental Health Nursing: observations from the inside

If the book's title does not suggest the challenge to come then perhaps the editor's "Our apology" just might.

https://www.pccs-books.co.uk/products/critical-mental-health-nursing-observations-from-the-insideThe editors declare the limitations of their apology as mental health nurses (mhn) given the precariousness of life, the environmental situation, the power of global corporations and how the industrial-military complex can also affect and define the role and work of mental health nurses. It is clear, that for example, the past decade (at least) of mental health service provision and development has been impacted by political and socioeconomic trends. The reduced number of mental health beds; the subsequent phenomena of out of area referrals (that also redefine 'area'). This past month, commentators have pointed to the lack of a work-force plan that should precede NHS Long Term Plan.

From the start the vocabulary here is rings of 'anti-psychiatry' and seeks, if not redress, then redesign of formal mental health services. Anyone putting the book down at this stage would be doing themselves, patients, carers, health and social care and their own learning a great disservice. Clearly, it is not only that existing services are reductionist, invalidating, self-serving, drug-pushing and re-traumatising; but the editors stress it is how they are all too often experienced.

As a mental health nurse the introduction and apology gets to heart of the matter, if not the mind. All of what mhn's do is tinged with coercion; whether with people on locked wards or those in their own home. The list of what mental health nurses are party to is a long one and makes difficult reading: the detention and restraint of people and administration of antipsychotic depot medications. The profession hides behind the ethics of acting in a person's 'best interests'. The negative impact of this experience is not just limited to a vulnerable minority who are in most marked emotional distress, but others as the book attests. If this suggests a caveat, there are several, as I hope this review across several posts will reveal. That custard cream shared with a patient (person, householder, tenant, citizen...) in their home will never taste the same. So, more on that to follow and not just to address any sense of trivialisation, but the many caveats that apply.

The editor's frame their apology outlining the basis for mhn: as a profession, a university degree, codes of conduct and accountability. p.viii As a 'profession in our own right' the critical thinking we espouse (yes - here too) and are supposed to exercise has failed to question and counter the increase in detention and the assault on mental health services themselves. At one stage I believed there was some coherence to mental health policy development, but if it is there now - it is intangible in its quality. MHS have not developed progressively as might have been anticipated if not exactly predicted. As a new Community Psychiatric Nurse in 1985 I am now a 'Community Mental Health Nurse', what else might my colleagues and I have become? At the end of the day we may longer return to the hospital (Winwick, Eaves Lane, Ribbleton - all gone), but what are we returning to when we go back to the office, the base? There is an office move in this book; and the final chapter considers the profession's very title.

The editor's apology does not just set the scene, it places mhn and all practitioners on the stage - front and center. This RMN (SRN) (to be ageist for a moment) is all too aware that despite all the talk about the need for integrated, holistic, person-centred care they are, more often than not, still lacking. I've come to see these as 'legacy issues', but that is another 'book'?

The book itself has 260 pages in total. The cover of my (softback - as above) is a pleasing contemporary design. The mainly white cover is already a suffering grey as it's been on numerous trips. Thirteen chapters follow the apology and an introduction. There are notes on the editors and contributors. The print is an excellent size and the overall format easy on the eye. Even if lightly edited, the editors have done a good job as the chapters cohere. Two indices cover names and subjects and are sufficient. So with chapter 1 beckoning I was all-eyes and ready page turning...

Thanks to PCCS Books for my review copy.

Sunday, January 27, 2019

RCGP’s 6th Health & Justice Summit: Safety through Continuity

Perhaps I will see you in Liverpool, UK later this week? 
I will be taking notes and look forward to reporting here.

A 2-day summit organised by the RCGP Secure Environments Group in partnership with, Broadmoor, Ashworth, and Rampton high secure hospitals, Spectrum, Care UK, NHS England, Martindale Pharma, Nottinghamshire Healthcare NHS Foundation Trust, Betsi Cadwaladr University Health Board, HMP Berwyn, West London NHS Trust, Mersey Care NHS Trust.

Following on from our successful event in Glasgow in 2017, we are now focusing on ‘Continuity of Care – safety through continuity’ as this year’s theme. We recognise the need to embolden the links between primary and secondary care for people resident in secure settings and are looking to showcase examples of good practice on how we can improve on care transition to the community.

The first day will broadly address physical health in secure mental health environments, and the second day will address the health needs of people in other custodial environments such as prisons, immigration removal centres and YOI’s.

If you are registered as a delegate for the event, please register which workshop you would like to attend via the link below:



n.b. There are two papers listed in the bibliography (please see the sidebar) that show how h2cm is very relevant and applicable to this specialist field.

Saturday, January 26, 2019

"Bounded epistemology, language and context of disciplinary thought ..."

"Effective learning does not happen in a content vacuum*. John McPeck (2000) and other critical thinking theorists argue that teaching general thinking skills and techniques is useless outside of a particular knowledge domain in which they can be grounded. Similarly, Bransford et al. (1999) argue that effective learning is both defined and bounded by the epistemology, language, and context of disciplinary thought. Each discipline or field of study contains a world view that provides unique ways of understanding and talking about knowledge. Students need opportunities to experience this discourse and the knowledge structures that undergird discipline thinking. They also need opportunities to reflect upon their own thinking; automacy is a useful and necessary skill for expert thinking, but automacy without reflective capacity greatly limits learners’ capacity to transfer their knowledge to unfamiliar contexts or to develop new knowledge structures." pp.48-49.

Anderson, T. (2008) Towards a Theory of Online Learning, (Chapter 2). In, The Theory and Practice of Online Learning, second edition, Edited by Terry Anderson. AU Press, pp.45-74.

*To an extent, however, learning often challenges the values we hold. When we experience new roles and must attain and maintain professional standards we may need to inculcate (tread upon) what we already know. A degree of unlearning may be needed, entailing a suspension of content as new understanding, insight and awareness is demonstrated. In the health and social care context, Anderson helps us appreciate the level of complexity in the number of disciplinary domains that must be negotiated and integrated conceptually and the requirements for person-centredness. It might be argued that this is a contributing factor for effective lifelong learning? That is, having the ability from early in our educational careers that we are capable and willing to 'refresh the conceptual slate'?

[Even as I cling on to the four-five care or knowledge domains.]

[Thanks: Centre for TEL]