Records I: Idealism, Comprehensiveness and who's that behind the tree?

[Opening thoughts: Even in the 21st C. idealism peppers more than philosophy; influencing education, professionalism (in all fields) and much more. The comprehensive ideal is not just the preserve of education; it is spread widely...]

Where does idealism lie in records?

If you are a health or social care student reading this, then (hopefully) a good dose of idealism (plus your bursary and future prospects!) drives you on. This idealism, transformed into motivation, helps to ensure that your written efforts - both course work and clinical notes - are worthy of earning the ticks-in-boxes and your mentor's signature. These in turn reflect your aspirations as a professional and all that entails.

Your clinical records and theoretical accounts of care (assignments, case studies...) must also play the role of a bridge facilitating travel between practice and theory. Your idealism makes you a runner, an athlete of the gaps. As a student you are still learning how to navigate the QUAD. What is this 'space'? What corners can you cut? No, first let's cover the corners that must remain forever 90 degrees! As a student - and a lifelong learner - you help question existing practice.

As soon as we first pick up those crayons we realise that comprehensiveness is readily applied as a measure for many processes in which '100%' becomes or is associated with the ideal. The usual association calls upon comprehensiveness as a property of information - as are validity, accuracy, timeliness and others. Records and information do not sit still. They are full of energy. True, when the archivist gets hold of them that energy may be potential rather than kinetic, but in use they are multicontextual and travel takes time. Perhaps, this is how - as our records (and information) travel hither and thither - comprehensiveness sticks out its big foot and trips the unwary traveller. As all learners negotiate the QUAD, they need guidance, support and protection. The QUAD really is a learner's paradise, but there are dangers out there amongst the sun-dappled trees....

Keep your (socio-technical) eyes open, because sometimes when you least expect it comprehensiveness teams up with idealism AND policy to create conceptual (if not practical) mayhem. Tree of knowledge - yes sure - but keep an eye on the fauna.
More to follow...

Music / concert visualizations

Continuing the graphics theme, I came across this post at Josh's blog American Sector:

Better living through charts and graphs, highlighting Andrew Kuo's graphics who blogs at Emo + Beer = Busted Career.


The images are not dynamic and I'm not familiar with the content, but they show that in trying to push the envelope we also need to fully explore the intervening space.

http://www.nytimes.com/imagepages/2007/06/10/arts/10kuo-graphic.html

http://www.nytimes.com/imagepages/2007/08/26/arts/26kuo-graphic.html

http://www.nytimes.com/imagepages/2007/08/19/arts/music/20070820_Kuo.html

Update on CHE Northern England group meeting October 13th soon.

Visual Patient Drug Interactions Display (when?)

This past week I've been reminded of the complex health and social care problems that an individual person can present. These problems with multiple pathology can mean that 2-3 clinical consultants are involved; a key focus of their input being specific advice on prescribing across neurology, mental health and physical care respectively. In between are families, care home staff, home management, acute, primary, secondary care and the care commissioners all striving to provide the best care possible amid a complex situation.

In such instances of shared care I wondered about what technology can bring to bear in terms of visual tools. Polypharmacology is the permanent front page headline of our Caring Times. Is it possible to present graphically the medication list for an individual and have the latest dynamic clinical and pharmacological data presented and coded in graphical links between the drugs? As drugs are added or excluded, could the efficacy of the drug regimen be measured? Eventually, lab results might also be factored in. Thinking of technical and engineering applications the tools are probably already out there?

I've done a brief search, but have not found anything significant so far beyond this tabular HIV drug interactions tool. There are bound to be many projects and research papers out there. Perhaps the pick-list tabular format is sufficient? The principle of KISS should apply here given the safety concerns. The data to feed such an illustrated beast is loaded not just with facts and (marketing) hyperbole, but major socio-political issues too. Fancy graphics may add complexity, not reduce it?

Such tools are inevitable though. Can you imagine (amid possible cries of heaven forbid!) when the public have access to pharmacological knowledge and the referral battle is one between the medical decision support system as it supervises requests and suggestions from the 'patient' (i.e. the patient's e-health care manager) regards their drugs. Of course, in future as drugs become personalised the demand for this may reduce..?

A standardised way to display drugs information graphically, revealing at a colour-line-sound coded glance the various interactions would be a major step-forward. I can just see the clinical consultants being able to remotely annotate and update the shared drug display with their notes. The patient and/or their family also being privy to the dialogue.

The existing tabular format is text-bound to struggle as bio-genetic data is added to this personal prescription suite. Another search shows that XML, XSL and SVG can all help to make this happen. I hope so and soon.

Dying 47-Year-Old Professor Gives Exuberant ‘Last Lecture’

Dying 47-Year-Old Professor Gives Exuberant ‘Last Lecture’

1 hr 44 min 8 sec - 20 Sep 2007

Description:
Randy Pausch Almost all of us have childhood dreams: for example, being an astronaut, or making movies or video games for a living. Sadly, most people don't achieve theirs, and I think that's a shame. I had several specific childhood dreams, and I've actually achieved most of them. More importantly, I have found ways, in particular the creation (with Don Marinelli), of CMU's Entertainment Technology Center (etc.cmu.edu), of helping many young people actually *achieve* their childhood dreams. This talk will discuss how I achieved my childhood dreams (being in zero gravity, designing theme park rides for Disney, and a few others), and will contain realistic advice on how *you* can live your life so that you can make your childhood dreams come true, too.


Thanks Randy. Brilliant an inspirational light! Bless you, your family and all your friends.
PJ

Award winning educational video, Vis Lab & Martian caves

Here are a few links:

Mars is pure enigma tainted red and placed in the sky with warm cave entrances spotted at night. Drawing the retrograde motion of Mars was a powerful early lesson on the power of manual visualization (paper and pencil).

VISUALIZATION LAB UC Berkeley.

Sense.us below provides a pdf and a 20MB video:

Voyagers and Voyeurs: Supporting Asynchronous Collaborative Information Visualization

Looking at the potential of these tools health care managers and decision makers are going to have indigestion. Health care information departments will no longer be playing catch-up, but will be providing data and information (directly or through a clearing service of some sort). The key issues then will be analysis, interpretation-significance and action. That latter point seems a perfectly timed invitation for public engagement, engagement beyond tokenism.

I found this short (award winning) film entitled TEACHING TEACHING & UNDERSTANDING UNDERSTANDING, very interesting especially in light of the deep post last weekend. For me this video highlights a role for Hodges' model in education. If students arrive at university with a well-used conceptual framework will they be predisposed to deep understanding?

Global Conceptual Frameworks & GANM I

Hodges' model was created in the NW of England
by Brian E. Hodges in the 1980s:

In order to make a difference
it needs to multiply across the globe

Imagine then
the cascade of change
the emotional chain reaction
the flash of light
that will follow

Imagine when
more than 6 billion butterflies

flap their wings

- even if only for one day.

SCIENCES links: Holistic Bliss or Tristram Shandy ... V

Finally: what of the content of the SCIENCES links page? Firstly, a little background -

Hodges' model has a key role to play in engagement. In health this means helping people to help themselves. Assist them to use the knowledge and experience they have of their illnesses. When necessary educate them - patients, carers and the general public. Use the latest research to further health promotion and preventive measures. These efforts, these messages though must compete with an awful cacophony of noise - political and cultural in the media - that is frequently itself awful dross.

Little wonder then that the science, educational and political communities are so concerned about the public switch-off, with citizens ill-equipped to critique and engage in debate on key SCIENCE issues - biotechnology, nanotech, astronautics - funding!

Engagement is not for everyone of course, but surely we can do better this?

Over on this right-hand MECHANISTIC side of h2cm what should political expectations (aspirations!) be regards the holistic bandwidth of a given citizenry? What does the 21st C. curriculum for the citizen look like? Is it as taught, the written, the learned, DIY, the 'take away', the media delivered or the hidden, ...?

Back to the task at hand: Like all the links pages SCIENCES also places health related subjects uppermost for ready access together with selected conferences. Not surprisingly ANATOMY & PHYS are first on the top row, followed by selected NURSING AND CARE THEORIES. If the h2cm website has any roots as a project it started here and spread.

The media in general and IT commentators in particular stress information overload. The relentless increase in the volume of information year-on-year has a prime contributor amongst the research community in medicine.

When we speak of General Practitioner (family physician) it seems increasingly difficult to determine what is general? There are so many branches of medicine even before specialised directions must be taken. The costs and risks associated with 21st C. medicine mean that filtering the research literature to find the treatment pearls is crucial to effective practice, outcomes, management and policy. So, EVIDENCE BASED PRACTICE (EBP) that utilises e-libraries and electronic databases is the tool of our times and with QUANTITATIVE RESEARCH completes the top row.

Before moving down a peg (if digression sensitive turn away now).

If you look at Hodges' model and its quadrants with a nurse's eye, you know for intramuscular injections the dorsogluteal - the upper-outer quadrant of the buttock - has been cited as a preferred site. How fitting then that the upper-right quadrant in h2cm is the SCIENCES. Problem is of course upper-outer translates as upper-right AND upper-left and sticking needles in people is a pretty invasive and mechanistic task. That upper-outer LEFT quadrant in h2cm translates to the humanistic [INTERPERSONAL] domain, so sticking needles there may be anatomically correct, but epistemologically speaking where are the talking therapies? (The model also at this point invites dialogue and debate on addiction.)

Recently, I've been researching a paper on socio-technical structures (which will also attempt to explain the hyphen), this project-making or -breaking conjunction of the social and technical for me begs the question of the locus of INFORMATICS. There are many schools of informatics in addition to HEALTH INFORMATICS I & II. If it is sensible to ask of these informatics fields, which h2cm domains would they claim as their primary home? [COMMUNITY INFORMATICS is listed in the political domain.] The great and ongoing efforts in CLINICAL CODING AND CLASSIFICATION within medicine are also listed here.

I've often wondered about how much duplication there is in the various electronic databases that are available? What metrics would you use? There's a major Phd study for someone there if not already completed or under way? We see rationalisation in other industries, business sectors until then (or the semantic web) the plethora of available resources in INFO SOURCES further extends EBP. In artificial intelligence pruning the search is an essential strategy. Is the internet tree still growing or shrinking? I understand it is actually shrinking - rationalisation has begun?

The next three categories represent a key personal interest of mine. IMHO graphics, diagrams and visualization can help conjoin health, informatics, h2cm and the wider world; hence DIAGRAMS and VISUALIZATION I & II. Is there a role for DIAGRAMmatic reasoning in health and social care?

It could be argued (and has been) that visual literacy is yet another educational milestone.

PROGRAMMING is great fun - if you are not concerned with hydraulic control systems, air traffic control software, or clinical systems. MARKUP LANGUAGES variations of XML have proved revolutionary. In reading about and my initial tinkering with Drupal, XML is in there (and so much more). In education and nursing theory much is written about the need to bridge the theory-practice gap. Perhaps the gap is necessary: a velodrome has to have a centre. XML is a software technology that can bridge gaps in transforming data, information and knowledge.

As in other domains I wondered where to place ENVIRONMENT & ECOLOGY? In the four introductions to the website, I've stressed the relationship (dependency) between green issues, health and our quality of life. ENVIRONMENT & ECOLOGY should ideally reside in each of the domains, or at the centre the 5th domain - the spiritual - made up of all four.

Our VIRTUAL creations and worlds are presented next. IF you want to conjoin data sources, users, and present information & engage users, THEN use the senses that are available. Health and social care records can benefit from visualization as tantalisingly glimpsed in early work on visualization in the social sciences. (I'll see if I can switch these around a bit.)

Next: ASTRONOMY: Orion - you started this journey from my bedroom window. Rising in Winter standing tall then giving way to Spring. We need to give the real stars back to the people:

Turn off the light,
take a deep breath and relax

[Engima - Mea Culpa]

SCIENCE could comprise so much more space permitting just one scratch of this surface - pharmacology, chemistry, physics the new disciplines all deserve listings of their own.

SCIENCE is most clearly evinced in MATHS & LOGIC that provide the basis for ENGINEERING. The final two categories return to programming. Compared with the others this final row is smaller. I have to contain this pantological journey. The H2CM links pages are big enough: I know my limits.

The final category RUBY [TOOLSET] is perhaps poetic justice since programming is oft described as SCIENCE and ART. One thing that Hodges' model is about -

folding time and space.

Child well-being, Silver Superdreams, DEEP care and DEEPer voices

On the website [archived 2015 - page may not remain] there's a small page that highlights DEEP things...

That is DEEP ECOLOGY, DEEP TIME, DEEP SPACE and of course DEEP CARE. These days it seems everything is DEEP. So it isn't noise that's damaging your ear drums it's pressure.

When I wrote that page deep care was left to fend for itself (there's a books worth there I bet); but then I remembered a day as a student...

In those days I had a silver Honda 250cc Superdream. I'd swear that bike had a built in gyro (except for the time I dropped it in the snow). The bike not only helped me with the a2b; on community experience I had to spend a day at a children's home...

The day started at 2pm working through to 9-10pm. Many of the kids were not yet home from school. So I was able to chat with the house-mothers as the two female staff members were called and I do remember their names. This was a quiet interlude before the chaos ensued. It was spring and the 'instructions' were - when the children are home, join-in outside while tea is prepared.

Well, arrive they did and there I was in this big garden playing football and inevitable rough and tumble with the lads. While all this was going on I could see the house-mothers at the window watching. Watching a bit more. Then not just watching: staring. Was I doing something wrong (and who was cooking tea)?

Anyway, a bell announced tea time to be followed with more antics outside then some indoor games and then time for bed. Stories first of course. I was asked to take a youngster upstairs and settle him down. He couldn't have been more than 5. On my shoulders up the stairs. A brief flight through the air along a carefully judged flight-path suddenly filled with giggles to find the book...

As I started to read one of the house-mothers came in and started to tidy the room and I suppose keep an eye on me. I like reading. As I read that feeling returned - being watched just like in the garden. This time it was a pair of very young eyes doing the staring, with an open-mouthed intensity that was dry-mouth disturbing. Next, I noticed the house-mother had stopped what she was doing to watch and listen. OK: What was going on? We reached a point were the book closed and it was time for lights out and prayers.

Then I was asked for a kiss.

It wasn't that I was upset or anything, but it was the way this little guy asked.

Now I know there are all sorts of considerations these days, equality and diversity, sex and gender roles. This WAS ALL about equality and diversity and something wasn't right.

I responded with that student-male awkwardness that I wasn't about to kiss him, but it would be great to shake his hand and say thanks for everything - the soccer, chocs, drawings, thumbs up for the bike....

So, phew - lights out upstairs - it was time for twenty questions downstairs.

As the home got quieter by the second, the questions were well-formed, but had to wait as I joined the two house mothers sitting at the kitchen table for tea/coffee. Straight away they guessed my star-sign: Aquarius. OK... Then they apologised for staring earlier. I acknowledged that this hadn't gone unnoticed. They explained how pleased and totally fascinated they were to see the young boys able to interact in ways that they - try as they might - just cannot manage. The house-mothers usually read the stories and while I'm no bass-baritone, my voice - a lone male voice - had really struck a cord.

Unfortunately, back then there were issues about recruiting male staff members. I passed on those same concerns and my experience to the school of nursing. The house-mothers agreed that as a consequence there were potential future mental health issues being incubated there - the clients of tomorrow. They were trying to bring about change themselves.

That day will stay with me - I hope. As I rode home I knew it was a real gem in terms of learning experience. Scary, the notions of 'self' and 'others'. I wonder how things have changed in the homes and in society at large?

Bottom line: The parts informatics does not reach

I really must get on board the bus: there are many assumptions that people make, what a nurse does, the role of a social worker and such like. I'd assumed that the private health sector - in this case a provider of residential nursing care would automatically invest in administration and clinical information systems. Silly me.

I don't know if the home I visited is an exception or typical of this particular group, but the staff are not only struggling to provide the best quality care for their residents, they are struggling with paper. Where's the I.T.?

2007 heading fast towards 2008 why I.T.'s in plastic folders, pinned on the office walls, on the office desks, semi-scrunched into pockets.

There is nothing wrong with paper and after all these staff are expert in handling several types.

What I was told, is that when a home (or two) is acquired and there are examples of good practices in documentation these will be adopted by the new parent. That is good; nothing wrong with that, surely this is a key part of what acquisition is all about.

The problem is that amid these additions the whole documentation system is not reviewed and rationalised; so the paper-burden grows literally with the organisation. Conclusions:

1. There is a records management consultancy opportunity there for someone (race you!).
2. I did not have to wait to see and discuss my client. There were no clinical information system vendors cueing up to demonstrate their wares. So good news for clinical informatics suppliers: you have of course not yet covered the (w)hole market!
3. If this particular organisation is successful financially, how much more successful could it be if it embraced clinical and organisational informatics?
4. Does the Commission for Social Care Inspection (and other regulatory agencies) take informatics capability into account in their assessments? If the benefits of effective informatics are real then they must be represented in inspection reports: shouldn't they?
5. 'Success' what does this mean in a nursing home? Well, let's try marks out of ten -

• the bottom line in the Financial Times;
• the bottom line in the nursing home main office;
• the bottom line on that top floor with its residents, staff and relatives/visitors.

So, what is the real bottom line?

Out of sight....

SpacePort and Moon

There are a series of images on TechRepublic including:

The view from above is reminiscent of crop circles. Officials hope Spaceport America will be operational in late 2009 or early 2010.

Apart from the little matter of punching of a big hole in the atmosphere, it is great to see another return to the moon - this time SELENE from Japan.

Working on the socio-technical structures paper, I need to summarise existing socio-technical approaches in the literature. The moon will figure in this paper too - an ideal light to help explain why s-t perspectives are essential.

I visited a nursing home this week (not much choice there as a Community Mental Health Nurse for Older Adults): the surprise though - no PCs.

More this weekend...

[100th post] Care Programme Approach & Drupal NW England 10 Oct 7-9 pm Preston

With 29 posts in 2006 (from April) + 70 posts this year makes this the 100th post. Is there another 100....?

CARE PROGRAMME APPROACH [CPA] - MENTAL HEALTH
Working in mental health - policy, practice, professionalism are never far from problems. Problems that in the most extreme form can result in suicide and homicide. The costs associated with inquiries recently made the (Health Service Journal) news here in the UK; despite the financial input (£80M) subsequent change is apparently very slow in mental health services if it happens at all.

Through autumn:spring in a couple of posts I'll reflect on CPA with reference to Hodges' model and informatics. The magic wands will be found elsewhere; possibly when the results of a CPA review and consultation are published in November...?

I notice the CPA Association website is powered by Drupal....
(now the Care Coordination Association)

DRUPAL NW England user group
The 1st Drupal User Group NW England meeting will take place:

Date: Wednesday 10th October 2007
Time: 7pm to 9.30pm
Location: MOKA Cafe Bar (probably upstairs), Preston

Every: 2nd Wednesday of the month.

The details are on the DRUPAL UK website.

Italian IBM employees on strike on Second Life & VR in Nursing: an (old) story

I've been interested in Virtual Reality since TRON as this blog suggests, but just have not had the real-world time to get to grips with SECOND LIFE and other virtual worlds.

I came across this post from Loïc Le Meur - serial entrepreneur and blogger. It's quite a RW - VR development:

Italian IBM employees on strike on Second Life

In the UK (and elsewhere) is this a way for workers especially in the public sector - prisons (which hit UK news this past week) and health to take action without as Loïc Le Meur's post explains holding anyone hostage?

<->

This seems really corny now, but back in 1991 I wrote a 'story' on VR in nursing:

WHERE HAVE ALL THE NURSES GONE?

A short story subtitled:

"... LISTEN NURSE, I’M SEVENTY NINE, YOU’RE EIGHTEEN -
YOU CAN’T SEE MY PROBLEMS"

As a student on my first ward 1977-1978 I remembered what an elderly lady said to me ... wish I could remember my response...

SOCIOLOGY links: Holistic Bliss or Tristram Shandy ... IV

I've introduced the rationale behind the content of the INTERPERSONAL and POLITICAL links pages. Let's now look at SOCIOLOGY: Although the ticking of the clock has a mechano-quantum constancy, people are collectively nudged forward through the 7 AGES that characterise our personal and social lives. These two lives beg a question in terms of Hodges' model and its four care (knowledge) domains. From what I've already said chronological age is mechanistic; but if that is the case in which domain does pathological age reside? Perhaps it is not just one domain, but a matter of span ;-). If for you this means or includes traversing the SCIENCE and SOCIOLOGY domains; that is quite a journey, so better prepare...

Following this on the SOCIOLOGY links page - can that be HEALTH PROTECTION & PROMOTION? Again!

Well yes it is and this is not a mistake. Just an effort to emphasise the need to direct our attention and resources at health promotion and prevention at a community AND individual level. Visiting Assen in the Netherlands last month you hear of the Dutch love of bicycling. Seeing is believing though and all ages were out and about. Marvellous to behold.

If health and communities are about support then there are a multitude of groups and networks dedicated to the task for PATIENTS and CARERS. The emphasis now is also to engage the public in service and policy development. They also need to be involved in public health, health and social care research and not just as 'subjects'.

In terms of Hodges' model contrast this journey - SOCIO-POLITICAL with the SOCIO-SCIENTIFIC referred to above. Another post perhaps....?

Similarly, there are PROFESSIONAL and other associations across all disciplines. This includes the notion of integrated services, still a long way to go. These professional groups are 'political' in the [ORGANISATIONAL] sense, but I wanted to reflect the social - socialisation - aspect. (What! You've done one row! Come on Jones hurry up!)

The phrase COMPUTER SUPPORTED COLLABORATIVE WORKING (CSCW) is not used as widely these days, but it captures a key purpose in HEALTH, SOCIAL & COMMUNITY INFORMATICS whether at an international, national or local level. Although I have placed it on the INTERPERSONAL page EDUCATION is all about 'socialisation' and an ongoing debate.

SOCIOLOGY I & II speak for themselves and in there you should find medical sociology and narrative medicine. Surely, the SOCIOLOGY listings should have pride of place here? The position of SOCIOLOGY on this links page is not intended to reflect examples of various socio-political concepts such as demotion, loss of status, alienation... It is true, these can reach over the INDIVIDUAL-GROUP axis and pummel the individual; but -

No. As with the other links pages SOCIOLOGY sits on the 2nd row due to the needs of health and social care learners (ALL staff!), patients and carers (the Public) to have speedy access to the relevant links.

QUALITATIVE RESEARCH is next and the ongoing quest for more effective methods and tools to help unravel the phenomenological world. As with QUANTITATIVE RESEARCH in the SCIENCES listing, I've included some examples of software tools.

The final row presents ANTHROPOLOGY in which medicine and SCIENCE will find their earliest roots. Fittingly then HISTORY is right alongside. Two listings are devoted to ART, CULTURE, MEDIA and TECHNOLOGY; a realm I could really get lost in if I had the chance. I've tried to include some of the best examples of various genres, but they change so quickly. Please let me know (through the website) if you've a gem or two.... to share - or if you notice any broken / outdated links. I use tools to check, but they are digital and of course on this [HUMANISTIC] side of h2cm everything we touch is 'analogue'(?).

As you may have noticed this SOCIOLOGY domain is the smallest with just 12 listings. Perhaps here with the POLITICAL domain in the lower half-group hemisphere of Hodges model more (people) really does mean less? Yet, another post perhaps...?

Although ARCHITECTURE seems to epitomise -

• the physical world with its presence (whether loved or abhorred);
• the notion of artefact on a grand and detailed scale
• the mix of mechanism and material
• ....

Architecture is also associated with the human spirit, the ephemeral. I have wondered about including the subject here. It is a truly colossal micro-macro subject and also a profound factor in the health and well-being of all of us.

Like health it touches all the knowledge domains....

Next! Last but not least SCIENCES...

Drupal, the website, comments and Apple

Whenever I've trained people on some IT application or other I always stress the obvious....

Make sure you log-in, or use 'x' regularly otherwise you know what they say...

If you don't use it - you lose it...

I should learn to take my own medicine, so with Drupal and Ruby I need to immerse myself and roll around a bit at least every-other-day , if some of this is going to stick. It needs to stick because I sure don't want to touch the existing content in terms of layout, styles ... (this time of year up North in Lancashire it's getting too scary).

In April on holiday in Crete I read through (a good beginners guide) David Mercer's Drupal book; well it's open again. The necessary software is in place, the only thing that troubles me are the themes and the existing home page plus getting to grips with the various WAMP components. Vital administration aside, can I create an original homepage in Drupal that reflects the model? Looking at the first database created using MySQL it really is a whole new venture. It forces you to take a completely fresh look at what you want to do and why. One thing I want to do is to create an archive for the existing - rather dated - content and see where we are.

There's a Drupal UK group and things are happening in London (as I learned in February!) but there's no group in the NW of England. Although....a forum search revealed that someone last November was wondering about a NW England group and now we've made e-mail contact so something is in the offing...! So IF you should be local - Liverpool, Bolton, Preston, Wigan, Manchester.... Chris and I are wondering about meeting once a month - Friday night. More to follow...

Before I close and the comment spam also takes full hold: just to say I've switched comments off. If you wish please get in touch - you can email me h2cmng AT yahoo.co.uk


(Oh yeah - Apple! 3d star maps, BYTE mag, laptops.... We'll bite into that another time.)

The photo was taken from a taverna in Plaka after we had visited Spinalonga on the boat - the island in the distance.

Thresholds: Bubbles and Lemon Washing-Up Liquid

When as a student I accompanied the Community Psychiatric Nurses on my first home visits (c.1980), I remember the extent to which the basics were highlighted:

• you do not enter until invited;
• you are a guest and may be asked to leave at any time -

(which was another way of saying you are not always welcome);

• listen, observe, accept - don't judge but do learn.
• don't take things personally and speaking personally look after yourself.
• what you see (just outside, hall, lounge) does not always reflect the true domestic picture -

(which is another way of saying what's in the fridge...?);

• you don't venture anywhere else without a clear clinical rationale -

(if in doubt seek advice, supervision, support)

• and so on...

This mix of guidance, good manners and common sense and a return to clinical practice these past months has prompted reflection on the threshold presented at people's doors and the fact that health, social care - life no less - is full of them.

Each may mean the turning of a page with no chance of going back....

I arrived to do a visit recently to find a bottle of apple washing-up liquid waving in my face. As I looked at the bottle one of the tiny bubbles floating inside without a care decided to burst.

"This isn't what I wanted! I wanted lemon!". I had crossed this particular threshold to try to persuade the vexed individual before me that perhaps they could not safely cope and manage there any longer, for reasons causing acute concern to several people and agencies.

"I wanted...." There was a stark contrast in the attempt of this person to exercise choice over the washing-up liquid in what was theIr home and the likely degree of autonomy in their next home: a nursing home.

Critical as it is from a legal perspective - it isn't just walking through the front door of people's homes that matters. There are of course other thresholds. As a clinician what is your purpose in visiting and what is the client's mental capacity to understand why you are there? In what may follow how much choice will there be beyond meal time menus, eating in the dining room.....?

I doubt that washing-up liquid will be one of them?