Serres - Hodges Paper

Amid the festive yuletide I am completing the Michel Serres-Hodges paper for possible publication next year as a book chapter. (The web version is now rather out-of-date, but highlights the direction of travel.) Almost finished @ 6,999 words - although it's scary the things you (still - argh!) keep finding to revise, delete and add, plus some last minute and yet much appreciated comments that highlight the things authors miss completely. So, when is a paper 'finished'?

Well finished this one will be, as the deadline is the 31st December. Plus I must move on... I plan to e-mail the text tomorrow and then fingers x'd! If the paper is accepted it would be a great start to 2007.

My return to clinical practice one day per week has been postponed until March, but more on that another time. Speaking of which - I feel another post coming on as everyone's out buying boxes...

All the best for the Season and the New Year!

Beware Reflex Moves and the Triple Whammy

In the past working as a community mental health nurse, I had several referrals in which a house move proved a key contributing factor to mental health problems. I'm surprised that moving residence is not ranked higher in terms of most stressful life events. For older people though an often initial trigger to ensuing chaos is bereavement and the degree of stress this causes is obvious and well documented. It was Simmel the sociologist who highlighted the vulnerability of the dyad - the couple:

"for its life, the dyad depends on both its members; but for its death, the dyad depends upon only one"

Whether marital partners or not, we often take this relationship for granted. Key really is the word of choice here, because listening to the 'patient' tell their story you really wonder what prompts such a vulnerable person to put their keys on the market and re-locate? Often still in grief and depressed they are certainly not able to think clearly and make effective decisions.

If you work in health and social care this scenario will not be news to you. Whatever your employment status though you may (sadly) have personal experience when a parent has died leaving your mother or father alone. For many decades now families are tending to live further and further apart, fifty miles or more - transcontinental even.

Following bereavement the cry goes up “come and live near us, we’ll look after you!” Usually for reasons of longevity that call is to 'mum'. Statutory services don’t hear about the instances when this move is the best thing since sliced-bread, but they certainly do when it goes wrong. We can describe it in many ways, but the importance of place, space, geography, community, in short - home has repeatedly been stressed.

Helping pick up the pieces on many occasions three features stood out:

1. The changing demographic – ageing population
2. The highly personal, subjective, narrative, and qualitative content that arose in session
3. The special circumstances of the older person and their capacity to negotiate this critical conjunction

Plus: my need in 1997 to learn HTML.

Given population trends surely this problem will become more common? What do we know about this dislocation? How frequent does it happen, what are the time-scales, personal and family outcomes, what are the socioeconomic consequences?

Surely it is nothing other than pure sentimentality to say:

"I miss the squeaky garden gate, the GP (family doctor) I knew for twenty years, the people who stopped and chatted on the front, even that nuisance-dog-next-door-but-one?"

Is there a double whammy effect? 1. People previously very well medically for their age suffer acute anxiety and depression. Suddenly pathological age = chronological age; and the negative impacts this can bring. 2. While people who may have had stable longer-term chronic conditions develop additional emotional problems, possibly resulting in hospital admission?

Could there be a triple whammy? [Surely not. Enough already!]

Well, that re-location also means of course that it is a new health and social care team who must help this person and their family make sense of the situation and find their feet again. This 3rd whammy will have its own subtleties. The former doctor-patient relationship may not previously have been tested to this extent. The situation can also impact the health of other relatives. The case for electronic health records also comes to the fore.

All this resulted in the [former] website ‘Beware Reflex Moves'. The title announced itself and captures the situation precisely. Creating the site helped me learn HTML and check out the use of frames. It is not maintained, although I really would like to follow this up!

Being able to air this pet research question at the Ideas Factory in October, other people were certainly interested. Their research questions concerned the quality of care and support that follows 'sudden' versus 'anticipated' deaths in palliative, primary care and related care environments.

I must do a Hodges' matrix. One aspect to highlight would be INTERPERSONAL: counselling, psychotherapy POLITICAL: access to counselling services for >65s. Can anyone help out? Any tutors with a class of students who could take the existing website content and do an update - re-design?

At this time of year loved ones and the rest of humanity are always in our thoughts. Take care and beware those reflex moves ....

Hodges Model: Need for a glossary and a comment!

Claire's use of Hodges model in residential care highlighted that terminology is an issue for some staff. This reminds me that a glossary is underway, but who knows when it will be completed. Some of the terms listed at present include:

• Career
• Conceptual framework
• (Care) Domain
• (Knowledge) Domain
• Model
• Situated
• Syndetic

Claire's application also flags the need to think practically about the model and not to get carried away with jargon. As the Health Care Assistants are engaged in care delivery what terms are being used? Are there any terms also common to Hodges model that staff already used? What are the core terms within Hodges model? These might be terms that Brian used in his course notes, plus some additions. Definitions would certainly help people adopt and use the model in a consistent way.

If you have any suggestions about definitions that would help, or specific terms you would like to see in a Hodges model glossary let me know and at least they can be added to the 'to do' list.

Before I close - thanks to Dan Bassill, Tutor/Mentor Connection, Chicago for his comment (our first through Blogger) to last month's post There Are Four P's in "Hodges model

Dan is also using graphics to create a simple, visual understanding of complex community and health ideas and provides an example link.

Hodges Model in Residential Care, Ireland

Claire Welford, Clinical Link Facilitator – Gerontology: a joint appointment between the National University of Ireland, Galway & The Nursing & Midwifery Planning Development Unit, HSE West - e-mailed me to say she is using Hodges' model.

It was great to hear this news. I put some questions to Claire as follows:

Q. What attracted you to Hodges model?

A. Its ability to address social needs.

Q. What are your objectives?

A. To prompt staff to address older people's social participation needs in long-stay residential care. To include all team members in care planning, including Health Care Assistants.

Q. How are you finding using the model - pros and cons (any surprises)?

A. No major problems yet. Some staff are struggling with new terminology. So many staff are used to Roper, Logan & Tierney, which I believe is not suitable for older person care.

Q. What feedback are you receiving from staff and students?

A. Staff as above. Students are interested and their Clinical Placement Co-ordinators have attended the educational sessions.

Q. Any comments from your colleagues?

A. User-Friendly. Succinct.

Q. Did you use any resources from the website, Brian's notes for example?

A. I didn't really use the notes, just used the general theory and went from there myself.

Q. Have you created any tools to help you, or do you feel there is something missing?

A. I have included assessment tools for nutrition, pressure sores, continence, manual handling and falls risk assessment.

Q. Would you be interested in doing a podcast interview, (if I can fully master the technical aspects)?

A. Happy to do a podcast. It would be great to see Hodges' model used more.

Q. Can you tell me about your role and work Claire?

A. For my role please see above, while my research interests include:

* Promoting quality care for older people.
* PhD work looking at autonomy in long-stay care of older people.
* Person-Centred Care.
* Action research/Qualitative methodologies.
* Currently a member of the Departments research cluster for older person research.

Claire also forwarded a publication on care planning in relation to the introduction of this model.

It sounds like Claire's use of Hodges model is at quite a high level, which supports the idea that the model is not prescriptive in terms of care philosophy or approach (note also the range of assessment tools). The way the model has been adopted also suggests it is quite accessible. Hodges' model is helping to extend the thinking and reflection of staff as they assess, plan and evaluate care in the residential setting.

For some people there may be a problem with Claire picking up the model and applying it in this way. Where is the evidence that the model is being used consistently? What about quality assurance? This brief Q&A sesssion prompts many more questions, that I hope we will have an opportunity to explore in the future.

On the other hand information literacy and knowledge management allied with the Web, are supposed to encourage the dissemination AND use of tools and resources. Given Claire's role and skills she has made a professional judgement, evaluated and appraised Hodges' model and found it of potential use and has set about testing her assumption. She is not doing this alone, but has Clinical Placement Co-ordinators on board. Quality assurance and detailed research do need to follow (this is why I created the website), but lack of this should not hamper progress.

Claire asked about keeping in touch - definitely - and thanks++ for sharing your work.

[For an introduction to Hodges model there is a 30 minute podcast.]

What are you - mathematician, book-reader or book-reading clock-watcher?

Sometimes you don't realise you are on a long-term cherry-picking escapade. I say escapade because this captures the rather haphazard, accidental and part-time nature of my fruit gathering.

In 1992 in the Engineering Computing Newsletter [SERC] Science and Engineering Research Council's EASE programme #38 p.4-5 Michael McCabe asked readers - "How would you label the quadrants of this diagram?"

I cannot find the brief article "Human Factors Aspects of User Interfaces Design" on the web, but I kept the original. It obviously meant something to me, McCabe shows why...

As a mathematician you might choose -

A clock-watcher -

- for a book-reader.

And a book-reading clockwatcher -

So, how would you label Hodges' model and does this say anything about how you would populate and read the model?

Advocacy No. 2

Where was I..? Oh yes - if we have largely withdrawn from the role of advocate, than what is left politically (no pun intended)? The nursing pioneers set an agenda that in many respects we have still not addressed. They made a difference - have we?

So what was the agenda set by the nursing pioneers and why does this matter now? Amongst many other things their efforts highlighted:

* the elements of basic nursing care
* importance of data - information - knowledge
* the diverse scope of nursing (health care)

They helped to define nursing and what constitutes nursing's standing agenda items. This post is not a denial of progress, because of course giant strides have been made, but where are we now? And, more crucially where do we need to be in the next 10, 20, fifty years...?

I cannot speak first-hand, because I am no longer at the sharp-end of general nursing care. From what the media says though what frequently passes as 'nursing care' these days fails to meet basic care needs. Especially, it seems when older people are the focus care delivery. Lobbying and action to protect the tenets of high quality basic nursing care is ongoing. This, however, is were our language changes and we shift from advocacy at that nurse-patient level to activism. What can nursing do as the population pyramid changes? And this is just the start as the issues in-tray is overflowing:

* ecosystem health - global warming
* global health: Aids, diarrhoea, TB...
* migration - refugee status
* public mental health
* health promotion
* public literacy, engagement, expectations
* ...

In order to wave a banner (never a shroud) effectively, you need hard and soft data. A banner is insufficient. Yes, true - it might get you noticed, but attention span is all with this issue set. That data needs to be transformed into information, knowledge - in short intelligence. All too frequently the facts we need are incomplete, inaccurate, or too late. Two circumstances are guaranteed:

1. There are facts critical to furthering the cause and
2. they are totally absent
(and not expected to arrive within the interval of a pregnant pause)

So much of what NU S NG does remains invisible. This must change.

We noted previously what the students may ask, I wonder what the pioneers would say? One thing for sure - they would not balk at the challenge and neither should we. Nurses as advocates begins with patients and their care, but it should not and must not end there.