Rag dolls and empty bottles

Grief is a frightening character.

A thief who can steal you away and get away with it....

Why?

Because grief cannot be denied. We must leave that small window ajar, the spare key under the mat, best wear your collar loose for when you're grabbed by the scruff of the neck...

Sometimes he finds you 'in' when you wish he hadn't.

Like when you're driving on the motorway and the windscreen wipers don't work somehow. He strikes and turns the sensible into a non-sensible rag doll.

Spring last year I found myself with a choice - head North for home from the Midlands or head back in time. The time traveller with a penchant for the past won out.

I headed West past Telford then Shrewsbury into and across mid-Wales. The weather was strange. There was lightening, but no thunder as I crossed the border and headed into Wales.

Rain then sunshine. Through Welshpool, stopping in Aberdovey through Tywyn, I worked my way around the coast then inland towards Cadre Idris and Llanegryn.

Another Home.

It's no wonder time has mythic status. In the village I imagined, the house standing there, the worn step. The many passing feet, tiny hands growing day by day.

There was the former hotel, the school and old chapel. I could hear voices from yesteryear. And remembered my grandfather's steel stomach from working in the slate quarry. True grit. True work.

Heading NE I came to Bird's Rock.

I made my way to the top.

Walking and running alone.












The valley there stretched out before me was like so many in Wales, green, beautiful and timeless.



I could trace out my journey, along the Dysynni valley and see the bay in the far distance, sunlit and misty.

I stood reflected, remembered and rejoiced.

Savouring some deep breathes and that space, I noticed the strong breeze cutting across the Rock and my face. If my mouth was open I found I had become an open yet empty bottle. A special bottle - one of those human ones - full of raw emotion thinking about a lost other.

I've no idea where it came from but I'm still there

My lips moved but I did not speak.

The wind spoke my words for me.

"It's ok son I'm right here and always will be...."

HSJ Editorial 22 March 2007: Finance

Before my son's bike race at Darley Moor on Saturday*, I picked up the latest Health Service Journal and flask of coffee. Reading the editorial I was struck by the sequence of the two items and my experience or lack of it.

The first item 'Consistency and agreement are needed to spread success' concerned the Commons Public Accounts Committee report on financial management and its conclusions. These included the need to share lessons learned from successful financial turnaround programmes plus (paraphrased):

The performance of the finance function is too patchy, inadequate in more than a quarter of organisations. There are recurring problems with recruitment, training and development with the central issue being the role of clinicians in financial management.

The much desired engagement here is between senior clinicians and management. The recent BBC 2 series Can Gerry Robinson Fix The NHS? demonstrated the all-to frequent gulf between managers and senior clinicians.

Returning to the HSJ editorial: payment by results - the much vaunted tipping point for clinical engagement in finance has (thus far) not tipped. For mental health there's still time, but then déjà vu kicked in. Quite a few years ago I remember getting ready to catch micro-commissioning and run with it, but the pass never came. It is happening in some places, with big brother macro-commissioning. I was pleased and yet disappointed. Pleased because at the time I was Team Leader for a Community Mental Health Team for Older People and I - quite typically then and now for such posts - also had a caseload. The disappointment followed from recognition that not only had a learning opportunity been lost, but a management learning opportunity to boot.

Amid the taste of coffee irony filtered through: that missing tipping point, the need for wider cultural changes (service line accounting) and clinically in mental health (and elsewhere) the focus on risk. People 'at risk' must not fall through the net. Well I don't know the details of service line accounting and the like, but I do know that while planting trees provides instant results, it is labour intensive and risky compared with sowing seeds. After all - never rely on one prong when several can help get your point across...

Mr Robinson's series revealed that other clinicians can act as change agents. Shifting the risk context to finance, how many clinicians fall through the management net? OK, hands up, if like me seeing a bottom-line makes you blush? My 1st line management course was some twenty five years ago. Six, or seven years later saw me on a not-quite-a-middle-management-course. Then I listened out for him, but LEO (Leading Empowered Organisations) never knocked on my door. Yes, I could have chased this. ... If clinicians are soft-wired to take detours around financial centers, somebody had better make sure those seeds are carrots.

The second item concerned joint working - asset-sharing between the NHS and local government and the journal's features on patient-public involvement, population health-NHS-Local Authority, joint strategic needs assessments. It just struck me that there's so much we don't understand about the functioning of these distinct organisations. Will integration help, or is it creating another layer of complexity? I'm all for encouraging and nourishing new ideas, but how does your garden grow with too much nitrogen?

Up to a few years ago I had something in common with Alan from TRON:

"I don't even balance my checkbook on downtime."

Finances looked after themselves. Not any more: cue pension wake up call and we are all tax-payers...

Seriously though, where do we want our intelligence to be in 10-20 years time?

Imagine financial reports that also relate to local public (mental) health outcomes. Maybe these exist in some places? Now that's a code disc that really would summon in a new order. Make financial information relevant to the clinical practitioners who make up the [ holistic ;-) ] multidisciplinary team then the trees will start walking.

*Punctured!

Nick Edwards (2007) Comment, HSJ, 22 March, p.3

Holistic care No. 2: Definitions - pushing the envelope checking the corners?

Last month I posted about holistic care; where was I up to? Yes, of course definitions...

I came across this article that includes reference to Jan Smuts (1926) who is generally attributed with coining the term holism. The article also highlights that holism is often associated with alternative medicine. I'd like to suggest here that holism extends far beyond any specific school of medicine or new ageist theme. A conclusion reached from contemplating the state of the World and using Hodges' model. So let's consider holism as a feature, characteristic or principle of care theory, practice and policy. What follows may well apply generally.

To begin, if health and social care (plus pastoral) is to be person-centred and situated then agency (who) must be a central factor in defining holism - holistic care. Then I would add the concept of information followed closely by knowledge. Stepping back slightly 'holistic' in h2cm denotes openness, inclusiveness and comprehensiveness.

AGENCY: In Hodges' model I think there are four aspects to agency:

1. The person who is the 'patient';
2. The health / social care agent;
3. Others associated with the patient (family/friends as carers);
4. The population at large (local, national through global).

The definition of the health care agent can be described as idealised or actualised; implicit or explicit; indirect or direct(?)

Please pardon the verbiage here both that last sentence and the volume. I'm still trying to figure this out. If you hadn't noticed I'm scribbling all this on an envelope. Any assistance or suggestions gratefully received.

A definition needs to account for the way it [holistic care] is used in day-to-day language, across various settings and contexts. To explain a bit more: imagine there is a community service with a multidisciplinary team that is 'holistic' in that it includes all professional (qualified and unqualified) disciplines, and voluntary practitioners of care. In combination this holistic service bring with them a range of knowledge and skills that is comprehensive. There are distinct pools of specialisation, with the inevitable overlap of some skills - otherwise how could people co-work? So on paper this team could - idealistically - be said to be 'holistic'.

If, however, all of these agencies were to be involved in a single case, then another definition of 'holistic care' emerges. This highlights the importance of context on working definitions derived from the service (agent) side, in contrast to definitions from the patient (subject) perspective and policy (Government). If you need some indication for the level at which Hodges' model operates look no further. At this level the patient and informal (family) carers are also agents, supporting the notion of self care.

It could well be that the whole team are legitimately required to respond to a referral, but if not this would constitute a huge waste of resources. The actualised sense of holistic care is expressed in policy - interventions must be commensurate with need. We cannot divorce health care from governance and economics. In fact there may be a case of abuse to answer for. You really can have too much of a good thing.

Point #4 above may seem to stretch the concept of agency too far. Problems first launched in the 19th century are coming home to roost. There is (currently) nowhere to run or fly. The inclusion of local through global sense of agency is a MUST. Patient care is de rigueur, self care is a major challenge*, both are insufficient in terms of achieving holistic care:

Staff: "Always observe discretely and check the welfare and safety of the quiet, withdrawn patients in your care."

Student: "Who's that sat in the corner?"

Staff: "Where? You mean the lady sat in the other corner don't you?"

Student: "Hold on .. why - she's in all four corners, in fact she's everywhere..."

Staff: "Oh, yes that's right her name's Mrs Green and actually she's not so quiet these days. It's all very sad. We're trying to include her in things."

Student: "What's the problem?"

Staff: "Some very complicated and damaging relationship problems, gross personal assaults of the worst kind that we can't discuss here, but the lawyers are talking about crimes against humanity.... All her children are threatened. Goodness is that the time! Is it time for your break? Perhaps you could go try and speak to her. Better still maybe just listen..."

INFORMATION: If agency is primarily centred on the left side of h2cm namely the humanistic axis with the INTERPERSONAL & SOCIOLOGAL domains - then this needs to be counterbalanced if the model is to mean something. ICT (information and communication technology) IS an essential factor.

For our purposes though we need to fracture this union and separate out information, communication and technology (Intensely Confusing Terminology?).

If we untie the digital knot, then we can better reflect upon the sociotechnical dimensions of holistic care.

KNOWLEDGE: This brings us to the next definition that can be built on conceptual and prepositional foundations. A definition of holistic care relating to knowledge can (surprise-surprise) also utilise Hodges' model.

I've to pull-the-plug somewhere - sorry info and know are very brief. Thanks for stopping by awhile, safe travels until we meet again at this crossroads.

I hope you'll be back and that these reflections are helpful?

More to follow: Holistic care No. 3: Location

holism: Smuts, J.C. (1926) Holism and evolution. New York: Macmillan.

*The real challenge is avoiding the need for self-care!

Professor Enid Mumford

I am very saddened to hear of the death of Enid Mumford.

In February 2004 Prof. Mumford responded to my email about her website and sociotechnical design explaining her work and offering help if needed.

This was then and remains a great encouragement to me.

Now I wholly appreciate her situation, response and kindness as she stated - having joined the health care community for older people herself.

Bless you Enid and your family...

https://www.theguardian.com/news/2006/may/03/guardianobituaries.obituaries 
 

What Complex Threads We Weave

Two thoughts spring to mind when I look at h2cm's axes - INDIVIDUAL-GROUP and HUMANISTIC-MECHANISTIC. I wonder where they end and what does where mean exactly?

These questions prompted the combination of the model's axes and the care domains into a 5th domain: the spiritual. Could there be another view of this? Is it sensible to consider that a care concept lies at certain point on the individual axis for example? How does this relate to the mechanistic axis? Maybe this asks too much of what is a model to simplify complexity? Do these axes run-off forever? Do they join up at infinity?

When we think of 'where' we tend to think in concrete (literally) terms. But where are you on this image?

Although this marvellous picture of the analemma helps extend our (physical) notions of where, this photo has its limits in that it captures the view from a certain latitude (a specific context). There are others. Our Earth bound sense of place takes on S-N-E-W, but if we travel far enough ....?

The mobius strip is an object of delight.

Perhaps unknowingly we are all topologists...

Happy equinox! WherEVER you are.

(Holistic care 2 will follow - time wise having to rely on draft post bank)
Analemma image credit: Anthony Ayiomamitis

'Nursing' label: can I get away with it?

Next month this blog Welcome to the Quad is 1 year old. If you haven't noticed so far there is no 'nursing' label.

Many people (understandably) reason that:

Hodges' model is a model of nursing
models of nursing are 'old-hat'therefore - Hodges' model is 'old-hat'.

That's a great pity and a rather short-sighted view at a time when long range vision is crucial. If you work in health and social care, but are not a nurse - you are most welcome here! If you work outside of health and social care a big welcome to you also. I'd love to hear who is visiting the blog (mum is that you?).

Hodges' model can be applied universally. Although multidisciplinary working is the mantra for all workers there are few cognitive tools beyond the usual suites of office applications.

So while Hodges' model owes much to and has much to offer nursing and learning disability, I would like to continue to stress the multidisciplinary label; for the time being anyway ;-)
Take care - holistic care (definitions) to follow..
PJ

P.S. Drupal is working, Skype credit confirmed and config working again, must revisit the podcast 2 draft, but first reading for work ...!

an·a·gram: "Nursing Politics" = ...

"nursing politics" = "counting lips sir" (no comment)

"Health career model" = "cremated, hello Hera ..."

"nursing care" = "cures rang in"

or better still "curing nears"

or "curing earns" (really?)

or "incurs anger" (yep, nursing's a great job, but frustrating at times)

or "sun care ring" (Holistic care - New Age tendencies?)

"nursing theory" = "hurrying notes"

or "syringe hurt on" ( - entry?)

or "gunnery hot sir" (... then stop using depleted uranium!!)

or "hungry in store" (whatever happened to basic nursing care?)

Human Ecology (and East Manchester)

This afternoon I had the great pleasure of meeting four people in Manchester who are alumni or currently studying with the Centre for Human Ecology. The CHE is based in Glasgow and so we met to explore the possibility of a NW England CHE group.

My connection with CHE is limited to finding and linking to CHE many years ago. I've an interest in ecosystem health and the effects of urban and rural environments on mental health. I've also pondered a while on the mental health impact of global warming.

Before the meeting Andy took us from Piccadilly Station around the Ancoats - New Islington area part of historic East Manchester. Many former cotton mills are being regenerated. We were able to go into Royal Mills - 198 Historic & New Build Apartments; a stunning building and one of the first mills. No surprise there since Ancoats was the first industrial suburb. We were shown the show apartment, remarkably quiet, warm, stylish ... an award winning example of regeneration, although I'm not sure how affordable this development will be for many locals. That said, it seems the key to regeneration is to increase the local population, to attract new people into the area.

I visit the area frequently heading to Leeds on the train Nov-May and taking my youngest son Matthew to the Velodrome, but that's in the car. Walking is of course a completely different experience: the old pub, empty block of flats, new homes, old homes, homes now memories, the air of expectation and frustration - the people! We listened to two locals who chatted about the road and major alterations under way around the old Ancoats Hospital.

According to Andy who arranged things today there are 12 people interested and so more meetings will follow. Great to meet you all - Andy, Jessie, Criggy, and Helen. Thanks to Andy for doing this, letting me use Hodges' model as an ice-breaker and to all for your interest. I look forward to learning more about courses that CHE offers, your various interests/projects and the emergent NW group.

Next time I must use my camera! The single frame I did shoot will follow...

Website - spring (autumn) cleaning and the year ahead

Since starting this blog last April I've realised the website needs more than a spring (or autumnal) clean. In 1997 with Brian's blessing I blew the dust off his original notes and made these available to the wider world. Now though virtual dust is collecting, there's content that needs archiving, some that may be worthy of update and the rest ripe for deletion.

If I were a lecturer, focused on learning, teaching, mentoring and R&D related to Hodges' model, the current content would probably have a home in an institutional learning management system [LMS]. It would certainly help me to have the resources that academic ICT departments can provide. For many lecturers though the tools they use are not necessarily their personal and preferred choice. So, given my freelance-spare time status how can I take the site forward? Or more critically how best to engage others and create a community?

Whatever system is used in academia the LMS would encourage and include contributions from students. It is such an infusion - fresh blood and thought - that h2cm needs. The blog shows that there are some interested parties out there and actual users of Hodges' model too (I see a student's negotiation from h2cm to Casey's model as a positive not a negative). Now I'm not getting carried away (it would take a Shuttle flight to achieve that), but it's weird the way things seem to be coming together.

As a critic on Wikipedia pointed out the website is not even worthy of a unique url (web address). Well that is in hand, but which architecture and software should I investigate and ultimately select? SaaS, that is - Software as a Service is arriving in the education market with other Web 2.0 applications. For me Hodges' model MUST encourage and facilitate learning. It should not just be about learning management. Although to many my early Computer Aided Learning efforts on the BBC micro may be considered Noddy stuff, I did strive to ensure that the programs were not just page-turning exercises. Learning BBC BASIC with the arrays, loops and other data structures was a fascinating creative process. How to interactively marry a specific learning-teaching objective with a programming language / environment; all without the tail wagging the dog?

Those non-IBM PC beginnings have proved a negative in terms of lack of knowledge about networks, servers and more serious database and programming applications. Now though reading the pickaxe and Ruby on Rails I have to say: Ruby really rocks! There are data structures, methods and explanatory sentences that sizzle.

Needing a development environment for Ruby I found Eclipse. Then the Drupal meeting with Charlie the other week in London and a server and database are on the list. Now I've XAMPP installed aok and soon I'll know [thanks Roger] if I'm a few steps from having Drupal running properly. I've only scratched the surface of Eclipse, but it seems an excellent tool: a real diamond. In addition Eclipse was a key part of a presentation I attended this week on Open Source and Open Standards.

I clearly have many dots-to-join. A lot of this makes me feel dense, plus I do have a demanding day-job, but there's an equally intense rationale here....

The REAL problem is how to transcend slogans: integrated care, holistic practice, education and health for ALL, public - patient involvement, public [mental] health, e-citizenry, engagement... None of us can do that alone.

Salutogenic Perspectives and Supertankers - Public Health

Supertankers are BIG. Very BIG. So cantankerous they take 'ages' and lots of space (3 kilometres) to turn. Health and social care is in a difficult spot. It needs to change and turn in two respects. One is about perspective, attitude, mindset or raison d'etre; the other concerns a more physical volte-face: policy that frees practise.

So, firstly services need to mutate rather drastically, two faces are needed like Janus, able to look in opposite directions. Instead of (just) gazing into the past and future health services must be disease, ill-health facing AND also health promoting.
Secondly, in addition to the need to adopt a mythical visage, the health service needs to either challenge or perfect its constant-turning. By that I mean the one minute screening, assessing, planning and delivering 'traditional' care; while the next minute addressing a health promotion opportunity or more focused preventive programme.

The cacophony of demand for care services and our need to care means that we must re-turn to the same historic vista, back to the routine target-oriented (vital) business of vomit, piss, sputum, blood, fears and tears: day and night - 365/24/7. Well, what's the alternative? Two distinct services:

• A National HEALTH Service (a real one)?
• A National ILL-HEALTH Service (what we have now)?

From a resource and organisational perspective both go hand-in-hand. There is no choice. Is there? Like Janus's chronological duality, disease and health promotion are two sides of the same coin. The health team just have to get on with it: dealing with ill-health, while being ever-ready to be health promoting (even if all that twisting and political shouting flags their energy levels).

To recap then, health and social care workers need the skills and knowledge to look in two directions, treating the effects of ill health; while also promoting health and maximising wellness. Dedicated health promotion teams aside, they must constantly turn - switching to-and-fro - from one task to the other. Demonstrating Neo-like capacities, health professionals deal with disease with one hand, while waving health promotion's standard in the other; but unlike Neo in The Matrix there is no virtual escape. If only the phone would ring!

Hodges model can (as ever) help generate and support pathological (illness and disease) views of health PLUS alternative salutogenic* perspectives, that is - health promoting views.

When it takes an age to do something physically,
IF there is a way to do it virtually,
to see in two directions and do two things at once
in the blink of an eye THEN
let that be the start
a new vis~age
lead on.
(and don't worry - the phone is ringing) ...

*Sullivan, G.C. (1989) Evaluating Antonovsky's Salutogenic Model for its adaptability to Nursing, J. Adv. Nurs., 14: 4.

Image source: c/o Eric Sutic

Interactive Domain Model - Best Practice: Guest Reflection!

I'm really grateful to Barbara Kahan in Canada who has helped publicise h2cm as resource of the month last May and by posting a guest reflection on Hodges model for March 2007.

The overlaps between the Interactive Domain Model -

Best practices in health promotion/public health are those sets of processes and activities that are consistent with health promotion/public health values, goals and ethics, theories and beliefs, evidence, and understanding of the environment, and that are most likely to achieve health promotion/public health goals in a given situation.

- and Hodges' model are clear to see.

Before the International Date Line beats me entirely, happy St. David's Day to you Barbara and everyone!