- 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

Tuesday, July 30, 2019

Book: In Praise of Walking - The new science of how we walk and why it’s good for us

Count: the number of steps...?

You don't have to count - just walk ...

individual - self
humanistic ----------------------------------------------- mechanistic
group- population
"The sea squirt starts life boring, and gets more so, but along the way it does one thing that is very interesting indeed. In its larval stage this creature swims around the rock pool, its tail propelling it much like a tadpole's. Its talents at this time are not impressive, being  limited largely to staying upright and hiding from predators. At least it moves, though. When adulthood approaches that changes. It sticks itself to a rock, where it will stay fixed for the rest of its life. And the first thing it does upon finding a suitable site, the one interesting act in its life? It consumes its brain." Whipple, 2019.
In Praise of Walking

As you walk, let Hodges' model provide a cognitive map for your reflections ...

My source (several)
Whipple, T. (2019) Walking - our super power, Saturday Review, The Times, p.14.

Monday, July 29, 2019

The number of pages count:

Received in the post: an invitation.

For a medical MOT that would cost me £129 - which is a saving of £141.

I am informed that a competitor charges £564 for a "360" Health Assessment and £424 for an "Essential" Health Assessment.

Recently I spoke to someone who had major surgery and they remarked on the lack of assessment not on the medical side, but the social, especially in relation to discharge and the circumstances they would be returning to.

This example of apparent disinterest in a social assessment contrasts with practice in the past - several decades ago.

Apart from an awareness of  'silver clouds' and rose-tinted glasses what struck me was securing a sale by a manifest of paper:

The various blood tests that would be completed are detailed using medical terminology across four A4 pages. Depending on age there is a free respiratory screening too.

The following quotations (Alber, et al., 2017) state clearly the risks:
"There is a growing awareness among clinicians and health care scientists, that medical overuse comprises unnecessary health care lacking benefit for patients [3] or putting them at risk of harm outweighing a potential benefit [4]. Moreover, unnecessary medicine adds to rising health care expenditures [5] and a misallocation of scarce resources [6]. Asymptomatic individuals are at risk of being labelled as patients, causing anxiety and affecting their quality of life [7]." ...

"Moreover, in secondary prevention, risk factors are increasingly treated as diseases [8]. There is a tendency to screen asymptomatic populations at low risk and to label pre-diseases as manifest diseases [1]. Serum cholesterol levels are a good example of threshold lowering by shifting the boundary between health and disease [9]."

Over-treatment is also a problem in two critical and concurrent senses, as follows:

Developed health

Need to transform to
health promoting, educational, preventive,
self-caring systems.
Developing health

Need to prevent the inheritance of commodified health care and over-treatment.*

Alber et al. also provide a useful diagram preceded with more background:
"In primary care, the “quaternary prevention concept” [] was introduced (see Fig. 1 ) in order to protect individuals from unnecessary investigations and treatment. Quaternary prevention is a “new term for an old concept: first, do not harm” []. It refers to actions “taken to identify [a] patient at risk of overmedicalisation [= in the sense of medical overuse, author’s note], to protect him from new medical invasion, and to suggest to him interventions, which are ethically acceptable” []."

Fig 1
The concept of quaternary prevention. Source: [] Kuehlein T, Sghedoni D, Visentin G, Gérvas J, Jamoulle M. Quaternary prevention: a task of the general practitioner. PrimaryCare. 2010;10:350–4, and [] Jamoulle M. Quaternary prevention, an answer of family doctors to overmedicalization. Int J Health Policy Manag. 2015;4:61–4

Without being dismissive of screening and its relation to health and well-being, I have removed myself from this particular mailing list.

At some point I must really apply Hodges' model to this discussion. The model is ideally suited to navigating and arguing this debate; from self-care, primary care, prevention, population and global health. I have posted previously about the damaging ideal of the comprehensive health record and the way that records seem oriented to assessment and risk reduction with outcomes and relapse prevention an after-thought. This defensiveness is critical for public safety, professionalism and accountability, but as a thread on twitter shows it can have a negative impact too.

*There is an additional confounding factor at work in developing nations, the incursion of digital technologies from outside.

Alber, K., Kuehlein, T., Schedlbauer, A., & Schaffer, S. (2017). Medical overuse and quaternary prevention in primary care - A qualitative study with general practitioners. BMC family practice, 18(1), 99. doi:10.1186/s12875-017-0667-4

Tsoi, G.W.W. (2014). Update On Prevention - An Introduction to Quaternary Prevention, Medical Bulletin 19, 11, NOVEMBER 2014.

I am subscribed to a mail list that is an invaluable resource on the status of medicine and health care, with contributors including, Mohammad Zakaria Pezeshki, Juan Gérvas, Karenleigh A. Overmann, Gene Tsoi and others.

Sunday, July 28, 2019

Thursday, July 25, 2019

Viarama: VR for good

Viarama is looking to recruit an ambassador or patron to help us reach a greater audience for our work, and ultimately help many more people in the UK. If you know someone who might like to help please ask them to get in touch!

Viarama is a world-leading social enterprise that delivers virtual reality sessions in schools, nursing homes, hospices, respite centres and hospitals. When I tell people that, their reaction is often one of polite bemusement.

‘You take virtual reality into a hospice’? They’ll ask, brows knitted together. It’s a valid question I suppose, especially if it’s the first time you’ve heard of the concept.

The first time Viarama delivered a VR session in a hospice I was totally unprepared for it. When you consider that we were the first company in the world to take VR into a hospice, how could I be anything else? There was no rule book, no cheat sheet, and no procedures to follow. We were pioneering and it was an adventure.

St Columba’s was the first hospice we worked with, and the first hospice I had ever visited. When I first arrived I was met with a perhaps surprisingly relaxing atmosphere upon arrival, and the warm and welcoming smiles of the reception staff went the rest of the way to rendering any preconceptions I had completely redundant. One thing quickly becomes obvious; this is not the place you thought it was.

What did I expect? Well I’m not sure now, looking back. Perhaps a sombre place, where the atmosphere was somehow more sad? A place where that-word-we-must-not-utter was everywhere?
St. Columba’s, like all of the other hospices where we’ve worked, is a place where extremes of human emotion happen, but as such there are a great many positives to take from any hospice visit. That the nurses and the doctors and everyone else who works there care so much for others is deeply moving to me, as it reflects humanity at its greatest. That we care for each other is a testament to our true nature and when you see that unfolding in front of you, you feel its power.

We’ve had so many wonderful sessions at St. Columba’s. One of the most memorable was with a lady I’ll call Ellen. Ellen was in the last weeks of her life when I met her, and was also in considerable pain prior to our visit. As such she was unsure if she would be able to participate. Bravely, she said wanted to give it a try, and as her bed was wheeled into the room where we were working I was immediately struck by just how frail she was.

Her son and husband were there with her, as were two doctors from the hospice, Dr Lloyd and Dr Hall. Dr Lloyd and I worked on all of the sessions together, and I was always grateful for her professionalism, ready compassion, as well as her sense of humour which, for an Edinburgh punter, was remarkably advanced.

Ellen’s family were clearly very nervous as I spoke with them while Dr Lloyd completed the session formalities. They told me how Ellen loved to travel, and how snorkelling and diving were something she adored. With that in mind I gently lowered the headset onto Ellen’s head and let her take in a beautiful underwater scene. She was now suddenly on a coral reef at the bottom of the ocean. As she adjusted to her new surroundings, Ellen gazed in wonder at the vivid colours of the fish, turtles, coral, and other aquatic life all around her. Slowly you could see her raise herself up while relaxing her shoulders and general posture as she became more and more comfortable. She started to turn her head this way and that to see more of this beautiful environment, as she pointed them out to us and her energy level seemed to rise as she did.

We watched intently as Ellen relaxed, which in turn relaxed the rest of us too. After a few more moments she let out a deep and heartfelt sigh. It was a very beautiful sound to hear. At that moment Ellen wasn’t in the hospice. She wasn’t feeling pain, or fear. She wasn’t focused on her situation or the emotional state of her family. Nor was she worrying about her immediate future, or reliving her past. No. She was simply fully present in the moment, and enjoying herself.

Once Ellen had seen all she wanted to see underwater she asked if she could travel. Travel is a huge part of our work in nursing homes, respite centres, and hospices, and it is probably the most emotionally rewarding part of what we do. If you were in a hospice situation how much would it mean to you to be able to either revisit places of real significance in your life, or go to places you had always wanted to visit but were unable to? To once again be able to enjoy the view from your old house or your favourite part of the world at a time when you believe that chance has passed is a wonderful thing to be able to witness. For Ellen and for many other people, this experience would prove to be very meaningful.

The first place Ellen wanted to go was to where she and her husband had their honeymoon. I was completely focused on making sure Ellen got the most of out of her session which is just as well, as at that moment I must confess I was afraid to look at her husband in case it was all too much for him. Gently I guided Ellen to the beach she loved and let her take in that view. She said how incredible it was that she could feel the warmth of the sun on her face again. Now, fully relaxed, and with the room rapt in attention, Ellen softly broke into a broad and beaming smile of sheer happiness. It was an unforgettable sight which was deeply moving to witness. The tears we all had in our eyes were, surprisingly, tears of joy.

Ellen visited more places all around the world during her session until her energy levels dipped again and she had to stop. The emotional demands upon patients in this scenario can be great and we are very careful not to overtax them. As Ellen adjusted to being back in the hospice, she seemed to be very positively affected by her experiences, and she told me she was so glad she did it, and got the chance to see so many beautiful things and places around the world.

After the session Ellen’s son waited until everyone else had left and approached me. With tears streaming down his face he told me he hadn’t seen his dear mum smile in months.

To this day many people still don’t understand the benefits that VR can bring to people in a hospice setting or similar. We are slowly convincing people, often just one at a time. I believe this is essential and this is why I have started this blog; to allow our work to let many more people like Ellen feel the sun on their face one last time.

by Billy Agnew

Wednesday, July 24, 2019

Marrakesh Treaty - NZ responding to global 'book famine'

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

Marrakesh Treaty to Facilitate Access to Published Works for Persons Who Are Blind, Visually Impaired, or Otherwise Print Disabled

Monday, July 22, 2019

PRIMEtime CE: a multistate life table model for estimating the cost-effectiveness of interventions affecting diet and physical activity

When I saw Adam Brigg's tweet and thread the figure below stood out.

I have modelled some of the concepts using Hodges' model. I have added some additions, flagging gender* to highlight way this and other factors (often) need to be considered in a multicontextual manner.

There is a lot more of course, including the reference list; for example Squires, et al. which pose some interesting questions.

81. Squires H, Chilcott J, Akehurst R, Burr J, Kelly MP. A framework for developing the structure of public health economic models. Value Health. 2016;19:588–601.

Fig. 1 The PRIMEtime CE conceptual model

individual - self
humanistic ----------------------------------------------- mechanistic
group- population
over time

individual behaviours

model: outputs
Active People Survey


cardio-vascular disease - heart disease,
 stroke, diabetes,
 liver disease, cancers, raised blood pressure, cholesterol, and body weight

TIME: chronological-pathological

behaviours - social
over time

social care

socio -

population health

health economics
health care costs
social care costs
return on investment
- economics

My source (and do follow Adam's full-thread):

Friday, July 19, 2019

My Moon Mission? "The Stack"

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


Command Line Interface
Vagrant ...]
Drupal APIs
Themes & Modules*^
Create Custom T&Ms'
Saturn V Reference Dimensions: http://heroicrelics.org

The Drupal slogan is:

"Come for the software,
stay for the community."

The Stack

*What are the requirements of your project?
^What themes and modules are available 'out of the box'?

'If the themes and modules you require are not available you can create your own.

The idea of using Drupal (or other CMS) is to use the software to do the 'heavy lifting'.

Image source:

Thursday, July 18, 2019

ERCIM News No. 118 Special theme "Digital Health"

ERCIM News No. 118 has just been published at https://ercim-news.ercim.eu/

Dear ERCIM News Reader,

ERCIM News 118

This issue features a special theme that provides a vibrant illustration of a sample of the multi-disciplinary research activities which underpin the upcoming revolution of digital health.

Guest editors: Sara Colantonio (ISTI-CNR) and Nicholas Ayache (Inria).

This issue is also available for download in pdf and ePub.

Thank you for your interest in ERCIM News. Feel free to forward this message to anyone who might be interested.

This issue includes:

SmartWork: Supporting Active and Healthy Ageing at Work for office Workers

"“Work ability” has been developed as an important multi-factorial concept that can be used to identify workers at risk of an imbalance between health, personal resources and work demands[2]. An individual’s work ability is determined by his or her perception of the demands at work and their ability to cope with them. The current challenge in using the concept is to establish adequate tools to evaluate and measure work ability continuously, in order to capture the changing and evolving functional and cognitive capacities of the worker in various contexts.  ...

The holistic approach for work ability modelling captures the attitudes and abilities of the ageing worker and enables decision support for personalised interventions for maintenance/improvement of work abilities. ...
The modelling of work ability will consider:

• generic user models (groups ofusers),
• personalised patient models,
• personalised emotion and stress models of the office worker,
• personalised cognitive models,
• contextual work tasks modelling,
• work motivation and values." p.35-36.

WellCo: Wellbeing and Health virtual Coach

"The WellCo European H2020 project (2017-2021), delivers a radical new information and communication technologies (ICT) based solution in the pro-vision of personalised advice, guidance,and follow-up for its users. Its goal is to encourage people to adopt healthier habits that help them maintain or improve their physical, cognitive, mental, and social well-being for as long as possible. Advice is given through behaviour change interventions tailored explicitly to each user. These interventions range from setting social goals to recommending activities around the seven areas defined in WellCo: cognitive stimulation, leisure and entertainment, supporting groups, physical activity, health status, nutrition, and tips (Figure 1). The behaviour change concept leverages the Behaviour Change Wheel model [2]." p.37.

Research and Innovation: A Language for Graphs of Interlinked Arguments

Next issue:
No. 119,  October 2019
Special Theme: Smart Things Everywhere (see Call for Contributions)

Announcements in this issue:

Call for Proposals: Dagstuhl Seminars and Perspectives Workshops

ECSS 2019 - 15th European Computer Science Summit

ERCIM "Alain Bensoussan" Fellowship Programme - postdoctoral fellowships available at leading European research institutions. Simple application procedure.
Next application deadline: 30 September 2019

HORIZON 2020 Project Management

is published quarterly by ERCIM, the European Research Consortium for Informatics and Mathematics.
The printed edition reaches about 10000 readers.
This email alert reaches more than 7800 subscribers.
Advertise in ERCIM News

ERCIM - the European Research Consortium for Informatics and Mathematics - aims to foster collaborative work within the European research community and to increase co-operation with European industry. Leading European research institutes are members of ERCIM. ERCIM is the European host of W3C.
Peter Kunz
ERCIM Office
2004, Route des Lucioles
F-06902 Sophia Antipolis Cedex


join the ERCIM Linkedin Group

Thank you to ERCIM and Peter Kunz.

[WellCo reminds me of the efforts of the AffecTech initiative.]

Wednesday, July 17, 2019

Book: National Populism - The Revolt Against Liberal Democracy

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

"Universities are not here to make people feel comfortable or to allow only research that avoids causing offence. Nor are they here to coddle young minds and present to them an ideologically homogenous view of the world. Universities are here to pursue truth, engage in reasoned argument, support freedom of inquiry and nurture the development of critical thinkers." Goodwin, 2019.
This post also links with Prof. Land's keynote in Dundee.

Book review by LSE Review of Books

My source:
Goodwin, M. Mob rule is crushing the campus, The Sunday Times, 30 June, 2019, p.25.

Monday, July 15, 2019

Consultation NHS: People detained within prisons and immigration removal centres MHA

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


highly distressed state,
not aware of own actions, 
suicidal ideation / behaviours / risk

Mental health assessment and treatment

"Mentally Ill [?]"


"The most important thing for me ..."

2am on 19 October 2009
a motorway
south of England

(What is 'local'?)

units in
Wales - Northampton 

6 years ...

 "... and for those people who I know
have been through this process is
[1.] the importance of clear, decisive communication. In my case, [2,] the lack of information from my home team,  [3.] the loss of documents regarding the reasons why I was in custody, [4.] no clear decision making about why I was there massively affected me. Mostly, [5.] no one told me what was happening. [6.] It was a void of information for me and my family."

 under section 3 of the mental health act

"... remanded me to prison for my
own safety for psychiatric reports."

proposed guidance
 remand and transfer

adult prisoners
low secure units

proposed guidance relating to individuals held within prisons and immigration removal centres who have been detained under the Mental Health Act for assessment and treatment.

Source: Twitter - Blog post by Alison Boreham

The NHS Consultation (last week)

Sunday, July 14, 2019

2 + Everyone Else -1: Thank you Michael

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

All of humanity in one picture except for Michael Collins. Apollo 11, July 1969

"We choose ..."


Saturday, July 13, 2019

Motivating the Gut to Walk, to Run

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

"I must go for run again
 - regularly - 
build up the distance to long ..."

*Walk, run, do something ...

On long distance runs:
the body produces lactate -
 a by-product of muscles working
in reduced oxygen.

Guts of marathon runners nurture
colonies of bacteria that
can consume lactate.

The bacteria transform lactate into propionate.
Propionate "has been shown to
increase the heart rate and maximise
 the rate of oxygen consumption,
making it essentially a natural
performance-enhancing drug."
Whipple, p.13.

Scheiman, J. et al. (2019) Meta-omics analysis of elite athletes identifies a performance-enhancing microbe that function, via lactate metabolism, Nature Medicine.
*I'm sure I recall reading in Bortz's 'Next Medicine' stressing the importance of movement to independence.

My source:
Whipple, T. (2019) Gutsiest endurance atheletes have the running bug, The Times, 25 June, p.13.

Friday, July 12, 2019

Ekistics - Special Issue: Indonesia and the New Habitat: Urban and Environmental Challenges

Ekistics, one of the world's oldest scholarly journals for human habitat research and practice, was developed by C.A Doxiadis with the goal of creating liveable cities and thriving urban environments. The journal has provided an interdisciplinary forum for the scientific study of human settlements since the 1950s. It has recently been revived into an online version as Ekistics and the New Habitat. The journal is planning a series of special issues for various regions of human habitation around the world. In this call, we seek papers on the topic of Indonesia and the New Habitat: Urban and Environmental Challenges.

Cities in developing countries have become more urbanized and create complex urban problems and challenges. UN-Habitat introduces sustainable urbanization as concentration for future human settlements which is in line with the changes of the world scale. As a developing country as well as most populous nations in the world, Indonesia also experienced human settlements challenges particularly in the area of urban planning, basic infrastructure, housing and slums as well as the urban policies. However, the government of the Republic of Indonesia has shown its commitment to be part of the Habitat Agenda by actively involved and implementing the six themes of the Agenda.

This Special Issue seeks papers from academics, researchers, practitioners as well as observers which posit and analyses the problems of the cities and the new habitats in Indonesia in relation to planning and implementation of the six topics of UN-Habitat:

  1. Urban Demographics
  2. Land and Urban planning
  3. Environment and Urbanization
  4. Governance and Institutional
  5. Urban Economics
  6. Housing and Basic Services
Particular attention will be given to perspective that explores future agendas regarding sustainable urbanization and environmental challenges.

In this regard, the following topics are recommended to take into consideration:
  • Any aspect of the United Nations New Urban Agenda, in Habitat III, including reference to the Sustainable Development Goals.
  • Critiques on the local, regional and global policy of habitat development, design and planning, and urban transformation
  • Issues of architecture, urban design, spatial planning, housing, conservation, sustainability, livability, environmental planning and regeneration through a cross-disciplinary and/or global perspective.
We invite proposals engaged in the mentioned framework of topics above in the form of firstly, a short 250-word proposal/abstract by 1st Oct 2019. On-topic proposals integrating the above themes will receive an invitation to submit a full de-identified paper in Word.doc(x) file format for double-blind peer review.

Scholarly articles/reviews (full papers, double-blind review): typically, with title, authors, institutional affiliations, abstract, keywords, body text (5000-7000 words), and APA 6th References at the end of the article. Body text typically includes:
  • an introduction to a problem or topic outlining the need for the research,
  • relevant prior papers from Ekistics and other sources
  • the methodological or conceptual framework and methods
  • the summary of key results, findings, or reflective insights
  • a critical concluding discussion.
Scholarly extended Abstracts/Essays (1000-1500 words), Critical reflections of Practice (500-1000 words or so) and Book reviews (300-500 words) are also welcome: review priority will be given to full research papers with the criteria mentioned above. Please submit via the orange [SUBMIT PAPER HERE] button in this email.

Please note: there is a further concurrent call:

Saudi Vision 2030 - Habitats for Sustainable Development

Contact: Assist. Prof. Dr Yenny Rahmayati
Email: yrahmayati AT psu.edu.sa

individual - self
humanistic ----------------------------------------------- mechanistic
group- population


[ Smart 

Urban Demographics
Land and Urban planning
Environment and Urbanization


Housing and Basic Services

history ...
Ekistics 1957
Governance and Institutional
Urban Economics

'City'? Reflect on the city and cities as a structure and as content.

c/o Associate Prof. Kurt Seeman, Editor in Chief & Assist. Prof. Dr Yenny Rahmayati
(and my source)

See also:

Habitat 3

Ekistic Journal: Health and Mental Health

'ekistics' defined. 

[ an addition ] 

Wednesday, July 10, 2019

"Performance Piece" by Senga Nengudi

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

"Performance Piece" (1978) by Senga Nengudi

Thackara, T. (2019) Creative challenge, FT Weekend, Collecting, 27-28 April, p.3


Ethnicity - Pay Gap: in Hodges' model

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

Tuesday, July 09, 2019

Inaugural Scottish Threshold Concepts Conference: TCs in Action [iii]

Hodges' model is keyword or concept-based and so ideas, research with 'concept' in the title are a trigger for my attention, hence conceptual spaces, threshold concepts.

It sounds like the study and development of concept-based curricula would be a natural link, perhaps a question for a future conference?

The above comment was influenced by the title for next year's event:

Biennial Threshold Concepts 2020

"Threshold Concepts in the Moment"

University College London (UCL – London, UK). 8-10 July 2020

#UoDthresholdconcepts2019 prompted me to think about when a threshold is not a threshold but a liminal opportunity. Especially, when practitioners, learners and theoreticians look at concepts, new, or known in their own discipline but applied in other ways.

Perhaps, Hodges' model alludes to this with the distinct care (knowledge) domains. In each domain concepts are tainted in a certain way. Being sensitive to this and the effects of context is learning.

Brussow, J. A., Roberts, K., Scaruto, M., Sommer, S., & Mills, C. (2019). Concept-Based Curricula: A National Study of Critical Concepts. Nurse educator, 44(1), 15–19. doi:10.1097/NNE.0000000000000515

Sportsman, S., Pleasant, T. (2017) Concept-Based Curricula: State of the Innovation,
Teaching and Learning in Nursing, 12, 3, 195-200. https://doi.org/10.1016/j.teln.2017.03.001.

See also:
Inaugural Scottish Threshold Concepts Conference: TCs in Action [i]

Monday, July 08, 2019

Inaugural Scottish Threshold Concepts Conference: TCs in Action [ii]

After Prof. Land's keynote and the previous post on 'work-as-X' I can see the value of the academically agnostic - neutrality of Hodges' model in terms of the spaces it affords. It can be used to reflect as a safe space or problematic, troublesome or unsafe. As an example, consider the task of reflecting upon the current state of residential and nursing home care?

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

Next reflect upon residents and sexuality within these care environments. This could be from any perspective, or even work through several: resident, a new care worker, other team members, staff nurse, home manager, family member, GP, or inspector. ...

Prof. Land raised the matter of extreme vulnerability and experience of Syrian refugees. Individual and Population are forced through a threshold that is catastrophic: that of identity. The scale of this event is being stressed as an urgent issue that must be accorded attention in parallel with physical relief

Perhaps, it is not just individuals who must encounter and pass through a threshold in their learning, their liminal journey. The problems we face demands that disciplines must find the disciplinary bridges that will enable them to solve the interdisciplinary and even transdisciplinary problems we face.

Geopsychiatry is a key bridge here. Research has determined that trauma can be intergenerationally transmitted. Governments, aid organisations and policy makers must take this into account and not just respond with physical relief. Unfortunately, the imbalance that is a lack of parity of esteem in general physical and mental health has its global-scale analogue in humanitarian crises and conflicts, especially those that displace populations.

Prof. Land referred to eduChaos and this is where 'lived experience' is found: not just in 'real time'.


Uncertainty, kept repeating itself Prof. Land describing the work of Ilgen et al. (2018) and the need in (and through) education to find comfort with uncertainty. The challenge of this is acute in medicine and mental health care as Ilgen's work highlights. The previous post's nod to box-ticking and elsewhere the quest that is the 'comprehensive record' stresses at point of initial encounter - the initial assessment, perhaps to the detriment of an outcome oriented approach?

The question posed of "how professionals can manage the uncertainty arising from complex, ill-defined problems with conflicting assumptions, evidence and opinion" [another slide] is not just concept-bound as I tend propose. The terrain of Hodges' model can be used to map wells of uncertainty that help make the more certain, concrete data - information stand out. It helped me to see the situatedness of this discourse repeated. The definitions of 'uncertainty' and 'certainty' attributed to Ilgen et al. (2018) are a helpful adjunct to information science based sources.

In subsequent parallel sessions I switched rooms in  trying follow what was most relevant. First was,
'Where have all the empathetic professionals gone? An exploration of empathy as a threshold concept for the helping professions'. This provided a multidisciplinary insight into social work education, with overlaps that included safeguarding and child protection. Jayne Lewis's format had us engaged, well me clearly as I've no notes or photos. The talk of empathy made me recall twitter and student nurses remarks on their placements (accepting too that 'No news is good news') and student-mentor-placement relationships. If the practice/placement environment is stressed/contested for a variety of reasons, to what extent does this influence empathy role models, student experience and study of TCs? Do researchers need to record the emotional and political 'temperature' as a baseline measure?


Next, on the programme; TCs, medical students and population health learning. From an acute angle (I was late arriving) Hothersall explained a study with a small sample, and yet findings that (as ever) call for more study, with implications for teaching in the lecture theatre, as a whole, in practice and relevance for me.

I'm sure there are many threshold concepts in public health and public mental health (to ensure inclusion). Even if specialty posts in public health are filled 2013-2016 (and amid recruitment pressures) I wonder if there is an issue for students (generally) in the perception of  'public health' and their respective discipline? Is there something in the old debate of pure - applied disciplines? Do medical and other students feel they must focus attention on the 'hard' learning rather than the 'soft' fuzzy concepts that public health encompasses? What has been the impact of the most recent series of re-organisations?


Of course, given the big themes identified, for me, the first lecture 101 should include a conceptual framework that can readily incorporate the (socio-)technical, (psycho- socio-) political, conceptual and much more.

The presenter also informed us that a paper is in press: 'The Clinical Teacher'. These findings of concepts that were troublesome for students appears to support my '101' role for Hodges' model - but then I would say that ...

Tierney's Exploring threshold concepts in the scholarship of teaching and learning was a rich source on a model of scholarship (Trigwell, et al. 2000) with tables also drawing on Perkins (1999, 2006) that I must try to follow-up as with Visual Art as navigation of affective thresholds: implications for the classroom.

The afternoon keynote discussed The dual development of professional identity as physicians and mentors, with Profs Hokstad and Kvernenes. Using a narrative reading (Reismann, 2008) the content and findings to me call for simultaneous duality in identity, the medical and the non-medical (practitioner - interaction with the patient and their family), clinician and mentor.

Being struck by the thought (on science, knowledge, holism - whole / part distinctions) of Goethe in the past it was a marvellous to attend Jonathan Code's session; Mind the Gap - Ontological discontinuity as threshold concept. I imagined Hodges' model and several leaves in various stages of growth.

It creates an overhead for conference organisers, but video recordings would be a great help. I think there is one more short post on this conference.

Ilgen, J.S., Eva, K.W., de Bruin, A., Cook, D.A., Regehr, G. (2018). Comfort with uncertainty: reframing our conceptions of how clinicians navigate complex clinical situations.
Adv Health Sci Educ Theory Pract. Nov 2. doi: 10.1007/s10459-018-9859-5.

See also:
Inaugural Scottish Threshold Concepts Conference: TCs in Action [i]

Friday, July 05, 2019

Fallacies of Work as Imagined: c/o Steven Shorrock - HSJ Patient Safety

I came across the following image on twitter. The tweet is also copied below.

This post is prompted by one from 'The Varieties of Human Work' on the Humanistic Systems blog 05/12/16 by Steven Shorrock. The focus is understanding and improving work, and in his opening there is a sense of very large net having to be deployed to capture all the disciplines and dimensions that are invariably involved in work.

"One of these is the simple observation that how people think that work is done and how work is actually done are two different things. This observation is very old, decades old in human factors and ergonomics, where it dates back to the 1950s in French ergonomics (le travail prescrit et le travail réalisé; Ombredanne & Faverge, 1955) and arguably the 1940s in analysis of aircraft accidents in terms of cockpit design (imagination vs operation). Early ergonomists realised that the analysis of work could not be limited to work as prescribed in procedures etc (le travail prescrit), nor to the observation of work actually done (le travail réalisé). Both have to be considered. But these are not the only varieties of work. Four basic varieties can be considered: work-as-imagined; work-as-prescribed; work-as-disclosed; and work-as-done. These are illustrated in the figure below, which shows that the varieties of human work do usually overlap, but not completely, leaving areas of commonality, and areas of difference."

The varieties of human work.

It immediately struck me how well the diagram can be translated and transposed on to Hodges' model on several levels and as per Steven Shorrock's excellent post. I acknowledge I am playing with language, but initial thoughts included:
  1. As per Shorrock: the difference between how people think about work and how work is actually done.
  2. Shorrock explains how for example 'work-as-imagined' draws on the other forms of work.The level of overlap in between the forms of 'work-as-' is as diverse as the contexts that arise and constantly change.
  3. There are many 'gaps' identified in Steven's post [not in the sense of a fault with his post]. A subset of these may relate to the theory-practice gap which was one original purpose of Hodges' model, to help close this gap.
  4. Orders of scale: from a single action to a whole job and its specification.
  5. The way the 4Ps process, policy, purpose and practice can be used (I identified the 4Ps within Hodges' model, one per care domain, many years ago).
As has been pointed out to me (on twitter) the context here is 'work' and not healthcare, but as Steven notes there are many disciplines, with commonalities and differences. I am really grateful to Steven for his post, in which he also stresses the overlap. 'Work-as' is a flux. Hodges' model can be viewed through time as series of frames. Below are some rather unstructured notes [musings] relating and extending the context of Shorrock's image and post to Hodges' model:

individual - self
humanistic ----------------------------------------------- mechanistic
group- population

'Work-as-Imagined': Of the four P's I have placed 'PURPOSE' here, since the individual's purpose must (ideally) achieve synergy with colleagues and the organisational objectives and goals.

'Work-as-Imagined' involves thought (and so is infinite in variety) whether use of imagination is day-dreaming, or radically innovative. Until AI does take over, this is the 'meta' - cognitive domain. Amid many, Shorrock makes an important point in how we imagine the work other disciplines do. Often so many stereotypes follow that are often revealed in referrals and expectations. Shorrock highlights this at the macro level of policy makers [lower right in #h2cm] having to imagine the operational aspects of work; and the simplified accounts of surgery for a patient by anaesthetist and surgeon (while meeting the requirements of informed consent).

This domain may be 'work-preserving' in humanistic terms as it is the realm of tacit knowledge, creativity and innovation.

Although the artifacts of simulation are ultimately produced in the SCIENCES domain, they are 'imagined' in case studies and scenarios. Shorrock helps make it clear how much of work is theorised and practised virtually, but with recourse to imagination not technology.

Mental illness and the systemic - organisational response is mediated diametrically in Hodges' model. Ongoing critique of psychiatry and mental health services in some quarters appears to suggest that being unable to work-as-imagined here, means loss of self and identity that is then outsourced and effected by proxies and advocates. [Discuss?]

'Work-as-Prescribed': Reading 'prescribed' literally then drugs and other physical treatments arise here in the SCIENCES domain. The 4'P is PROCESS suggestive of procedures, specifications, instructions and formal rules. Process is important allied with PURPOSE in that if (your) can be described formally, by a set of rules then you may be vulnerable to your job being taken by a robot through 'robotic process automation'.

When I started in the NHS in the 1970s there was a shift taking place from being task-oriented (mechanistic) to individual/patient-centred (humanistic). Shorrock notes how there are relatively fewer examples of work-as-prescribed. Developed nations are waiting to see how many existing jobs are lost to AI and robots, but how many new ones emerge. (Can the developing nations 'skip' several prescriptions?)

Here, we also apply time to work. The past, current work and the future. Will we still work the same hours? Is there a lesson in '0' hour contracts? An obvious aspect of work is day vs. night shifts.

'Work-as-Prescribed' also reinforces the presence and context of the SOCIOLOGICAL domain. Now, conferences are devoted to 'social prescribing'. By its nature this is more often than not 'public' and therefore 'disclosed'.

Citizen science and patient involvement provide a further angle on work-as-prescribed. As does what is prescribed (especially in what is used) must to some degree influence what is proscribed in what is not used.

'Work-as-Disclosed' Sharrock writes concerns how work is explained and communicated. This will also involve teaching formally and health professional to patient, carer and public.  The challenge is that thinking about work and actually doing work is a SOCIO-POLITICAL act - transaction (as the literature demonstrates).
Socially, whether or not someone is working is also disclosed in their domestic  comings and going to work. The socio-political dimension is evident in the assumptions that follow homeless peopleand their apparent 'staying' (many do work?)? There are those who opt not to disclose at all and live off-the-net.

SOCIO-ECONOMICALLY there are constant references to 'pay-gaps' especially by those groups and their representatives most affected by low pay and austerity. While the social care workforce toil in the community, social care funding, provision and integration is pushed into the long grass that is green papers. Despite the social value and importance of this work, the status of this sector is signalled - disclosed as poor.

Nurses globally are campaigning to establish in law the requirement for safe-staffing levels. Sharrock alludes to the challenge of nursing as PRACTISED on the 'shop-floor' and ongoing studies on staffing - establishments and skill-mix.

In the 1980-90s expert systems specialists interviewed workers  in an attempt to understand the knowledge acquisition and elicitation associated were their profession - community of practice.

These humanistic care (knowledge) domains reflect the qualitative approach to research.

Work-as-disclosed also communicates to would-be future recruits. How are the aspirations of teenagers and mature entrants first experienced, discussed and carried forward socially?

'Work-as-Done' simultaneously speaks of power, employment, accountability and regulation. 

As four conceptual spaces #h2cm indicates the 'distance' between concepts that shifts according to context. The space that work takes place within and how people are managed, organised, controlled for efficiency with reminders, queues, appointments, and waiting areas are signs of the institution. The person was a long way from the creators of the Victorian asylum, even as they sought to establish (stamp?) a 'standard' level of care.

What difference does it make when work-as-done is bound to an individual and collective sense of duty?

The counterpoint is precisely [mechanistic] work-as-done. Work-as in shift completed and recorded - clocked as such. Work-as-done: the 12 hour shift or as already mentioned work-as-NOT-done due to the flexibility afforded by zero hour contracts. Work-as-done also denotes [scientifically] the concepts of power, energy and effort. So, work-as-done must result in personnel actually feeling 'done': burnt-out when safe-staffing is not assured.

The old saying: "If it is not documented it was not done.", springs to mind. Shorrock refers to surgery and loss of life. What was 'done' and what does an inquiry reveal? What is actually done and the way it is done if varies - contravenes 'norms' rules then there is a issue of whistle blowing. The question then becomes was the work done as it should - must - be? The 4P in this domain is POLICY. 

Perhaps a box-tick here also accounts for 'work-as-' elsewhere?