Composability: programming and caring

Composability: (Ruby Pocket Reference, O'Reilly, 2007)

The degree to which you can express logic
by combining and recombining
parts of a language (p. 136).

Composability within health and social care - is there a further definition...?

The degree to which you can express care situations
by combining and recombining
the parts of a language encompassed within a health and social care model,
(a dedicated conceptual space).

"...the most general and greatest concepts..."

But, although they
[i.e., the most general and greatest concepts]
may not have meaning,
they do make sense,
and it is very sensible
to awaken this sense from
time to time.

Robert Musil
Derr Mann ohne Eigenschaften - 'The Man without Qualities'
(first book), 1924
(translation by Jelke van der Pal)

Knowledge site 'Pass It Along' [IBM] & 6 New Scientist Autumn Specials

There is a new beta site for software and systems developers... by IBM 'Pass It Along' for sharing knowledge and expertise:




Also received - news of 6 weeks of New Scientist Autumn Specials:

Starting this week and running until 25th October issue, New Scientist will be featuring a series of special reports:

Sept 20th - Future car: electric or hydrogen?

Sept 27th - The seven biggest mysteries about the Earth

Oct 4th - Outer limits of the brain

Oct 11th - What would a world run on renewable energy look like?

Oct 18th - Excess: why we need a new economic model

Oct 25th - Defeating cancer

To blog or not to blog - that is the question?

Much has been written - blogged about even - as to whether clinicians should blog or not. In a recent HSJ article and the Health Service Journal's new blogs this question has been raised.

As the cogs turn, I'm a very small one; but even as a nurse and blogger I am acutely aware that being on the web is the equivalent of the old town square. That square is increasingly global (at the month's end).

The stocks sit there plainly visible, prompting pause for thought ...

Blogging on the HSJ Nadeem Moghal made the point about the risks of being a clinician, a blogger AND being tired and frustrated to boot. Mr Moghal also references a source which advises that clinicians should not blog.

There are reasons not to blog as a health service employee. Like everyone I get tired and frustrated too. You have to remember your contractual and professional obligations, plus your relationship (actual and potential) with the people in your care.

That said, the government, NHS, Connecting for Health and others need to consider what they want in terms of the skills and experience of the professionals it employs. Using nurses as an example - is it enough that nurses are 'IT users' and 'web-savvy'? Or should nurses, academics and other professionals be capable of critiquing the hardware on their desks, ward trolleys, the software they use (and help develop) and the associated issues that arise? In the sense that we are professionally accountable, then a given level of insight and understanding of new media and technology forms is vital. There are a lot of issues: take for example Rod Ward's recent post on access to records.

Perhaps some established journalists are worried about the changes in the(ir) business? I am part of that media demographic that Sir Michael Grade must worry about over at ITV. Being on the web means you watch less TV, amongst other things...

To agree that clinician's should not blog and close-up shop is to consider and respond to the situation in purely political terms.

Despite the dangers of being online - in person - I believe there is a case to demonstrate that this new media can provide a marvellous and effective outlet for new (and old) perspectives on what it is to care. Whether wearing a white coat, driving around the community or writing your latest post if you have a message then surely it can be delivered in a professional manner?

For me here on W2tQ
I've some help in not just having a message
but also having a mission.

To focus on the politics alone, is to ignore the role we also have in teaching and mentoring others. This should include not only students, but members of the public too: see Healthspace and personal health records. ... IT literacy, political literacy, health literacy, media literacy - there's no end to the 21st century skill set ....

So if you blog,
tread carefully,
listen and pay attention to the constantly breaking glass.
Politics (and your job) does count!

And yet blogging can be about more than just politics:
it can be about creativity and exploration.

h2cmuk at yahoo.co.uk

"Let us put our minds together
and see what kind of life we can make for our children."
--Chief Sitting Bull (1823-1890)

Image source: Tony Woof.com

Butterflies make the news go-round

In health, social care and the news media at large there are themes that recur. While every summer has its silly season, there is a strange irregular-regularity in the way the light is re-cast on issues important to us all. It may be triggered due to a tragic incident involving a child, older person, or a whole family. At other times the stimulus for further exposure and prompt for debate is found when different coloured papers have their political say. The political opposition can force or be forced into a reaction.

Chaos is hardly a new kid in town, but there are many groups such as Society for Chaos Theory in Psychology & Life Sciences who are trying to understand and apply this infant science to specific disciplines and even conjoin and create new ones. I mention chaos due the question of migration.

Where do the various items of news head to when they disappear off the media's smörgåsbord?

Maybe they are still there, they just merge into the background noise? This movement is not just a binary, metronomic tick-tock, in and out of the media's eyes. It's more complex than that.

Like the butterflies beloved of chaoticists everywhen, perhaps these issues travel an unpredictable and yet inevitable course through the four fold space of Hodges' model? They travel together and yet in separate lanes, like the horses racing at an amusement arcade. When one reaches the socio-cultural-political boundary, that is when things happen and the volume is ramped up.

Events may frequently have their origin in the intrapersonal domain (it takes a person to find a tango partner), but one way or another - either heading south through the social domain or east and south through the sciences domain - news worthy items will and do repeat themselves.

Original image source: http://10outof10.blogspot.com/2008/04/lorenz-father-of-chaos-theory-died-at.html

Mental health survivors create evolving timeline of the UK survivor/user movement

From: Jill Anderson
To: MHHE AT JISCMAIL.AC.UK
Sent: Monday, 15 September, 2008 17:08:22
Subject: Survivor/User movement timeline

The survivors history group has created an evolving timeline of the UK survivor/user movement. It can be viewed online at:

http://studymore.org.uk/mpu.htm#Manchester2008

Will be an invaluable resource for teaching.

Best wishes,
Jill
----

Here is one entry of particular note for 1894:
A short story Passed is the first known published work of Charlotte Mew. The writer, walking in a poor area of London (Clerkenwell?), visits a church. She sees a gospel that the priest at the alter does not:

"Two girls holding each other's hands came in and stood in deep shadow behind the farthest rows of high-backed chairs by the door. The younger rolled her head from side to side; her shifting eyes and ceaseless imbecile grimaces chilled my blood. The other, who stood praying, turned suddenly (the place but for the flaring alter lights was dark) and kissed the dreadful creature by her side. I shuddered, and yet her face wore no look of loathing nor pity. The expression was a divine one of habitual love. She wiped the idiot's lips and stroked the shaking hands in hers, to quiet the sad hysterical caresses she would not check. It was a page of gospel which the old man with his back to it might never read. A sublime and ghastly scene."

The description may shock (See also 1916), but compare with Jayne Eyre in 1847 and the Care of Children Committee in 1946. The outstanding difference is the compassion.
The partner web resource of the survivors history timeline the - Mental Health History Timeline - is also well worth exploring.

Jobs, the Specifics of care and feeling Special

Recently in applying for jobs - left, right and further off-centre - the penny drop is long confirmed: it is not sufficient to include statements such as - "I have very good communication skills". Would-be employers need specifics.

Patients and the public
(as the two previous posts reveal)
need specifics too.
They do not just want to be "one of the crowd".

A key quality of a 'good' nurse is that they can anticipate a patient's needs. Of course the whole care team are engaged in this activity. Foresight has always had a mystical quality to it, and no less today on wards, in clinics, even corridors ... community and occupational settings. ...

Anticipating care needs increases comfort, job satisfaction, saves time, money(?) and leaves people feeling better; even if they are far from 80-100%.

Good (effective) staff can use their knowledge, skills and experience plus that of colleagues AND the patient to head calamity off at the pass, whether in the form of emergency intervention, or a much needed bedpan and fan (you figure it out).

The key bit is what makes these special staff stand out. How they communicate this to the patient, the family and colleagues. This is why most staff and yet some staff in particular can make a world of difference.

Even if the patient is a member of the crowd,
the quality of the care interactions make them feel unique,
cared for -
a person who matters.

BBC R4 Today - NHS productivity

Following the post yesterday - Don't waste energy - use a care plugin... - there was an item this morning on BBC R4 Today:

0815
A report published by the Office for National Statistics suggests that NHS productivity has been falling by 2% a year. Martin Weale of the National Institute of Social and Economic Research, and Shadow Health Secretary Andrew Lansley discuss the efficiency of the NHS.

There's no transcript of the interview so maybe I was (still) dreaming? At some stage though this a.m. a point was also made about the public (as tax payers and patients) either wanting to go into hospital to be treated and cured (quickly and efficiently) OR have a 'good' (positive) patient experience.

Why can't the two go hand-in-hand -
especially with all the emphasis on 'partnerships'?

Martin Weale highlighted how efficiency is not everything - people may have other requirements. If a patient is treated very efficiently and quickly - all evidence based, latest and greatest interventions - but their experience is at best neutral, or at worst negative, then how will that experience affect their recovery, staying well - relapse prevention - and any future care episodes and admissions? Complex indeed ...

- and Remembering...

Don't waste energy - use a care plugin...

How often do policy makers refer to "joined-up care" while at the same time they strive for efficiency and effectiveness and the confusion that can arise there? As health and social care teams fall over themselves (efficiently) to deliver integrated and holistic care, they are also under pressure to attend to economy of effort. Resources are precious and must not be squandered. So often, despite the best efforts, the dots are not joined and the required rapid response falls short in terms of delivering interventions in the community that can prevent relapse and unnecessary admission.

There is no magic formula for success.

The management of complex care is - complex! There will always be the exceptions that challenge the scintillatingly best qualified, evidence based savvy, fully integrated, IT literate, multidisciplinary, Olympic standard health and social care team.

Given how readily we are seduced by the words we use, there is more holistic value to be found.

It needs to be discovered though -

So don't waste energy -

join all the dots and think holistically!

Image with many thanks: John Eric Hughes

Evidence Based Medicine & Care and the I-G Nexus

Great store is placed upon evidence based medicine (EBM), nursing and care. There are dedicated centers, conferences, journals, policy pronouncements and much more besides.

The evidence based approach has been subjected to critical review in leading health, medical and research journals and blogs. The status and presence of EBM as the bridge between clinical theory and practice is not in question, it is only right however that nothing is taken for granted. EBM is not necessarily as scientific - as objective - as the clinical trials and meta-analyses... make it appear.

Dr Nicholas Hicks provides a brief and yet informative piece on the definition and scope of evidence based health care on Bandolier.

The success of EBM depends however on the GROUP: the sensitive aggregation of results with the personal details stripped out (anonymised). EBM is still (rightly) subject to debate, its method and methodologies constantly scrutinised. In terms of contemplating the complete care spectrum Hodges' model places the natural home of EBM as being grounded in the SCIENCES domain. The POLITICAL domain provides a vital, supportive and reinforcing role through policy, governance and reporting, nationally and internationally. Subsequent studies are modified and refined to ensure lessons are learned.

The ongoing challenge that the application of EBM&HC presents can be found in h2cm, if we choose to reflect there. What we must never forget is that the benefits of EBM are delivered to INDIVIDUALS. Ultimately, it is they who benefit from improvements in treatments and care. It is the individual who remains at the centre of care.

"Evidence based" approaches are being applied in a great many disciplines, but it is the notion of EB care (EBC) as Hicks writes that deserves our special attention. Thinking back to basic physical nursing care c. late 1970s: whilst the best treatment for pressure sores is prevention, this is one area that has benefited enormously from evidence based research. For decades pressure sore treatment and care variously relied upon custom and practice, the myth of Sister x, y, z (or "we do it this way..."), to scientific scramblings, argument and debate.

EBM has recognised the need for quality as well as quantity.

There may also be a stark contrast between the time-scales of EBM and EBC?

If we split "EB" and the "C", we see that there is a danger that the 'I' may get lost:

• To what extent is EBM situated, such that the patient would also recognise the context?
• To what extent is EB(x) a baton for best practice? -
• That is, from the start lines in research lectures, learned journals, research supervision and international study centres - how easily is EB(x) transferred to wards and other clinical areas? (Having 'best practice' examples is the just the start: how will these be communicated?)
• Are the notions of 'holistic assurance and bandwidth' applicable and of value here?
• Is EBC patient AND staff empowering? Is EBC like EBM supported by the underlying (political domain's) foundation of policy and audit to ensure that change does happen and staff can deliver safer, more effective, individualised, person-centred care?

The best evidence is that gleaned from the source. This does mean the non-trivial task of juggling subjective and objective health. It means engaging with the patient and community. It means that the best evidence for care should also be timely. This may be a fuzzy form of EB(x), but in contrast to the steel bearing that EBM can often present, there are plenty of hooks that can make a real difference.

Source:
Sullivan, M. (2003). The new subjective medicine: taking the patient's point of view on health care and health. Soc. Sci. Med. 56(7), 1595-604.

Resource:
http://www.pickereurope.org/

Image sources:
(were listed.)

Computer Weekly IT Blog Awards (maybe next year!)

Returning from Szeged and Drupalcon I checked the Computer Weekly website to learn that W2tQ had not won an award. A disappointment then, but no great surprise - pleased to be shortlisted.

It was a real blast just being nominated and as they say there's always next year.

Many congratulations to the winners and thanks to everyone who voted for W2tQ.

Holistic care: What is 'holistic bandwidth'?

The old website with its pages is static. In thinking about how to mix the old and create new dynamic content for a Drupal based site, I came across a possible way to define and explore our notions of holistic care. Here are some very initial musings....

First to focus on quantity. In completing an assessment whichever care domain I start in (let's say the intrapersonal domain) then as that domain is populated can it be argued that within the other domains the same number of placeholders for our assessment data are created? If my patient has eight problems (and two strengths) then according to one definition of holistic bandwidth the remaining domains should have the same number of problems (and strengths). Balance in all things - including holistic care?

One thing that the ADLs teach us is that (holistic) care as represented in Hodges' model is asymmetrical.

This does not mean that the ideal of holistic care is lost.

It might mean that strident efforts to assure holistic bandwidth can interfere with our attaining person-centred, integrated and multidisciplinary care.

It is essential that we recognise holistic care as an ideal, as a constraint and the primacy of functional considerations in:

• assessment;
• planning;
• care interventions;
• evaluation;
• and governance.

It comes as no surprise then that there are several versions of holistic bandwidth:

1. If we want to be inclusive then version #1 is epistemological. This anticipates the total number of semantically associated concepts that can potentially arise in a given care episode. This is what might be termed the 'semantic web of care'.
2. The sum total of concepts across all the care domains (inc. spiritual) that are actually activated in the course of a care episode.
3. The concepts that are deemed relevant by the patient, carer, family and guardians.... These add holistic value to and may well (must!) overlap with the care concepts recorded by the clinical team and reflected in the health record(s).
4. The degree of expressiveness of the care recording system - its capacity to represent holistic care and capture (measure) holistic bandwidth pre- or post- care episode completion.
5. The (idealised and learner generated) collections of care concepts identified and enacted within education.
6. The idealised and actual collections of holistic arrays applied and recorded by the combined clinical and social care disciplines* involved (there are two sets in practise and theory). As per #3 these (should) overlap with the patient and carer's....
7. The final combined lexis of written, electronic and other record(ed) media that constitutes the final:
• personal health record;
• summary health record;
• historical health record;
• clinical record;
• ....
• all the above combined;
• an individual and group's (family) health career!
8. In addition there are the anonymised and aggregated data items that form part of clinical / management reports, local, central government statistics and returns that inform national health and social care policy and global health intelligence at the WHO.
9. Throughout 1-8 holistic bandwidth must also incorporate education, engagement and informatics.

It is reasonable to speak of personal and impersonal forms of holistic bandwidth.

Students - if this is helpful or confusing please let me know h2cmuk @ yahoo.co.uk