Hodges' Model: Welcome to the QUAD: February 2019

- learn about the conceptual framework Hodges' model. A tool that can help integrate HEALTH and SOCIAL CARE, INFORMATICS and EDUCATION. The model is situated, facilitates person-centredness, integrated - holistic care and reflective practice. A new site using Drupal is an ongoing aim - the creation of a reflective workbench. Email: h2cmng @ yahoo.co.uk Welcome

Thursday, February 28, 2019

Capital letter. Start of Sentence.

Prison, Offenders, Release ... in h2cm

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

Mental Health Assessment - diagnosis?
Learning disability
Ongoing counselling, legacy issues PTSD?
Addiction services
Custody Liaison Mental Health Nurses
Understanding of – my [care] plan,
stress & vulnerability, relapse signature
Literacies, writing, numeracy
Life chances
Key skills:
interviews, exams, assertiveness, strengths ...

Medication: prescribing, compliance,
concordance, safe prescribing
Addiction, Substance misuse

Assurance of physical health, exercise

Location – familiar with the area?
Logistics – transport
Treatment for Offenders

Sentence length

Re-integration into society
Social attitudes
Sex Offenders

Role of family
Relationships (Legacy issues - 'resolve'?)
The social network they may return to
Contact with a  support group*
Having a ‘buddy’ when available

Determinate Sentence (half)

Policy (integration?) and Funding
Offender Assessment System
Rehabilitation of offenders
Employment – work
Opportunities for training - education
Allocation to a GP and other health services
Organisation of State Benefits
Probation services, Charities
Statutory supervision
Mental Health Act
Community assignment

Once we have sufficiently addressed what is identified using Hodges' model, we can can stand together in the center with an improved chance of achieving person-centred care and Recycling Lives?

If you can suggest changes, additions, please get in touch h2cmng AT yahoo.co.uk

Tuesday, February 26, 2019

Period. End of Sentence.

"The strongest creature on earth is not the elephant, 
not the tiger, but the girl." 

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

Individual beliefs

Shame - Culture

Education - Access - Awareness


the 'Pad' Machine
OR in the Fields

Rags to Riches?

Period. End of Sentence. Official Trailer from Rayka Zehtabchi on Vimeo.
Riches to Rags?


Women's Rights

Freedom - Choice - Independence

Human Rights

Sustainable Development Goals - SDGs

And in the UK: c/o @michaelsheen & @HeyGirlsUK

Sunday, February 24, 2019

Special Issue: Critical Realism and ICT4D

The Electronic Journal of Information Systems in Developing Countries (EJISDC)

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



SOCIO - technical?

My source: https://twitter.com/CDIManchester/status/1098962321471348736

Thursday, February 21, 2019

1st Mental Health Nurses' Day - the View from this Bridge

To celebrate MHND here is a mix of personal observations and opportunities in mental health nursing ...

Theory ----- Practice
Beginner ---- 'Expert' in h2cm ---- Lifelong Learner
Career starter ---- Senior Practitioner ...

humanistic ----------------------------------------------- mechanistic
Not just Making a Difference but
trying to Make a Positive Difference, even in a negative light
Helping people help themselves
 Assure physical health in mental health ---->>
Mentor and Sign-Off Mentor
Don't try to be something you are not
Remember you were a student once
as a lifelong learner you still are and always will be
 Ethical and moral challenges*
Psycho-social orientation
So many opportunities, communities of practice: Experience of cognitive behaviour and family therapy
Nurses can be therapeutic agents - co-workers with patients esp. in relapse prevention

August 1977 'RMN' Winwick Hospital
'SRN' Wigan RAEI
(deemed necessary to achieve a holistic perspective)
Travel: Hodges' model inc.
Jordan, Amman;
Spain Barcelona;
Paipa, Colombia;
Ireland, Dublin;
Northern Ireland, Belfast
Opportunities in Research
AND Researcher's in Practice
Mixed-methods in research?
So much to learn and specialize in

Early computer aided learning projects 1980s-1990s

New website still to follow...!

Team work crucial*

Career co-supported 3 children

Community Mental Health Nursing 1985

Experience and challenge of project work -
primary care mental health

Guest in people's homes
Recognised importance of carer's role

'Community Mental Health' people still needed to help define what this means in the 21st Century.

Every "Thank you" speaks volumes, but differences of opinion speak louder - Respect

Even in situations were there is 'no' hope it is amazing the difference one self can make in reaching out to another, and what each can learn...

MHN is an amazing career...

Progress since 1970s in mental health care
Closure of asylums, unfinished project.
Change through policy, e.g. National Service Frameworks

National Programme for IT 2004-2007
Data Standards quarterly meetings 1997-2007

Future policy, incredible opportunity to influence, effect and witness inevitable change in mental health service provision
(see recent book review)

Frustration and Concerns:  -
TO DO (still) LIST
Public Mental Health - a Cinderella service within a Cinderella service - Parity of Esteem?
Use of information technology in mental health nursing

New starter? Engage with unions and professional bodies to assure standards, quality of care in the profession and public health

Wednesday, February 20, 2019

The Compass Rose in Care

*"A compass rose
is a diagram of
directions that is located
on every map or globe."

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

The Health Career rose
is a diagram,
a conceptual map of care 
that can be located within every 
care plan and health record?

*Source: https://slideplayer.com/slide/5847408/

Sunday, February 17, 2019

Waste not - Want not: An Item for Discussion (to refine) ...

Proposed item for discussion:

That this meeting reflect on the need and case for a generic and foundational conceptual framework across health and social care disciplines. This will help all (lifelong) learners to develop as reflective practitioners and critical thinkers to better support integrated and person-centred care, to appreciate and achieve parity of esteem and the leadership required to further high quality healthcare outcomes, health promotion and self-care.

Many nurses, including students, will no doubt have heard the words of wisdom: “Things go round in big-big circles, some of them decades long. You'll see!” We realise there are problems that seem perpetual. Health care seems to have its share of legacy issues, that is, problems that stretch across the decades and confound successive generations of practitioners, managers and policy makers. These issues are ongoing subjects for discussion and debate like this proposal. Nursing is a vibrant profession, things, including 'us' change. There are theories and practises that (thankfully) fall out of fashion. Nurse education is no exception with its own approaches. Some are permanent becoming accepted fixtures, while others wax and wane. Respective examples are educational technology, a fixture whether on the desk, one's lap, in the hand or simulation lab; nursing theory and models of nursing had their moment several decades ago as now they struggle for attention. To a degree this is understandable; curricula are over-crowded, practice must be evidence-based, healthcare is multidisciplinary, nursing is person, patient and carer-centred. Society also 'moves on'. Crucially, however; we must remember that to nurse - is to be a reflective practitioner and critical thinker.

Mention of models and theories of nursing may reveal something of the proposer. Much has changed for the profession since the late 1970s. Nursing [UK] has been challenged both publicly and from within; culminating in serious individual and organisational failures. Such incidents, plus associated reports and recommendations, called into question the quality of nurse education, nursing and care. No system is 100% effective in terms of checks and balances: to err is human. In nursing, however, our constant aspiration should be to disprove this fact of human frailty. In healthcare and nursing so much of what we do is predicated on the quality of our communications. Demographic trends impose pressure on proportionally fewer staff. There are more patients and carers who need reassurance, explanation, time and attention. How can nursing solve the ongoing productivity conundrum?

While communication is the common factor for all health disciplines and the essence of humanity, there is no accepted overarching theory of health communication. Although this may seem an academic question, in healthcare it is paramount. Poor communication can undermine shared awareness, responsibilities, understanding and is a constant factor in patient safety. Now, we must also recognise the patient as expert and raise the level of health literacy of the public. While there is progress in overcoming stigma within mental health, public mental health remains lost within public health. The issue of parity of esteem, extends beyond the much debated and still to be reconciled fields of physical and mental health care.

In response, this discussion calls for a generic, foundational conceptual framework across all fields of nursing, including midwifery, learning disability, mental health, veterans and prison services and end of life. If more argument is needed then without such a generic framework, the health and social care goal of our times - that of truly 'integrated care' - will just be (circular?) hyperbole. For the people who are self-caring and those in our care, the empathy and rapport they experience will more likely be process-driven, our patient-carer-public-centred care invariably off-target.

Supporting information:

Francis Report

NMC Code

NMC Revalidation

RCN: Revalidation

NICE: Reflection and reflective practice

HSJ: The importance of reflective practices

The King's Fund: Integrated Care
The King's Fund: Shared responsibility for Health

Health and Social Care Act 2012

Friday, February 15, 2019

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

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

"This systematic review aims to identify modifiable barriers and facilitators (determinants) of medication adherence in bipolar disorder. We also plan to report determinants of medication adherence from perspectives of patients, carers, healthcare professionals and other third parties. A unique feature of this systematic review in the context of mental health is the use of the Theoretical Domains Framework (TDF) to organise the literature identified determinants of medication adherence."
Of course there are many potential overlaps. For example, knowledge; the decision processes - to what extent are they collaborative - studies with patient involvement, also concerned with concordance not just adherence? Are they supported through the use of digital technology? Goals can be multiple as in person - patient centred, to support carers, policy development or an assessment instrument. That 'emotion' is all too readily experienced by families too in the event of relapse.

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

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

... Decision Processes (4)

(13) [Physical] Environmental Context and Resources

(2) Skills
(3) Social Influences

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

(13) [Political] Environmental Context and Resources

(14) [Political] Reinforcement. 

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

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

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

Patient Perspective

HealthCare Professional Perspective

Carers Perspective

Others Perspectives

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

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

See also: Elizabeth Mamo

Tuesday, February 12, 2019

Saturday, February 09, 2019

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

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

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

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

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

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

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

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

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

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

Critical Values Based Practice Network

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

Friday, February 08, 2019

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

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

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

c/o The King's Fund

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

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

Population Health (systems)

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

[Improving population health outcomes requires multiple interventions across systems]

'Making every contact count'

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

Integrated care models

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

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

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

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

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

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


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

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

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

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

Tuesday, February 05, 2019

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

Following on from Part i and Part ii.

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

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

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

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

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

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

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

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

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

Just two chapters and buy, buy...

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

Part i 

Part ii

Part iv

Bull, P., Gadsby, J., Williams, S. (Eds.) (2018) Critical Mental Health Nursing: observations from the inside, Monmouth: PCCS Books. ISBN 9781910919408

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

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

The Age of Surveillance Capitalism

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

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

Sunday, February 03, 2019

Theory on Demand #29 Good Data

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

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

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

Something you know


personal ethics

('good' data = 'here'?)


Something you are
Something you have 

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

'open data index'

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

data: "power in numbers"


bureaucratic ethics

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

Saturday, February 02, 2019

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

Following on from Part i

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

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

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

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

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

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

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

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

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

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

The person - individual - self

"proximal experiences"

"over the power horizon"
"distal power"

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

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

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

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

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

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

Parts iii

Part iv

Bull, P., Gadsby, J., Williams, S. (Eds.) (2018) Critical Mental Health Nursing: observations from the inside, Monmouth: PCCS Books. ISBN 9781910919408

Friday, February 01, 2019