'Nurse as Engineer' by Josefson

'Engineering' and 'architecture' have both been co-opted by cross-disciplinary explorers to help traverse what are usually cravasses between disparate fields. Or, if not a serious journey - more a day-trip than an expedition, it's an effort to create the impression of progress being (rapidly) made. Fields of knowledge being pulled - fused-together. These are transdisciplinary times:

'Individualization is best achieved in the engineering model, in which cach patient is seen as a unique case. The nurse collects and analyses the patients' data to arriye at a diagnosis, which includes, but is not limited to, issues that concern medical diagnosis and treatment. "The nurse sets obiectives based on knowledge and experience of what is desirable and achievable and designs an individualized care plan by selecting from a known repertoire of nursing interventions those most likely to lead to achievement of the objectives. After implementing the interventions, the nurse evaluates their effectiveness by comparing the client's subsequent condition with previous diagnoses and objectives."

In the last model - the non-routine model, which is a research model - the patient is still seen as unique. The problem is that the search procedures cannot be analysed because more judgement and intuition is required in making decisions.' p.25.

n.b. Two other models are described: the nurse acting as a craftsman; and the routine.

Josefson asks in a section (pp.28-29):

Who draws the boundary between Man and Machine?

Who - indeed!

Ingela Josefson. The nurse as engineer—the theory of knowledge in research in the care sector. In.  Knowledge, Skill and Artificial Intelligence. Bo Göranzon & Ingela Josefson (Eds). (1988), ISBN038719519X. pp.19–30. Berlin, Heidelberg: Springer-Verlag.

In the above paper/chapter Josefson draws upon the work of Katie Eriksson and Judy Ozbolt.

Previously: 'engineer' : 'architecture'

Masquerade in health care but on which level?

There is a Drupal module called Masquerade, the project page explains:

The masquerade module is designed as a tool for site designers and site administrators. It allows a user with the right permissions to switch users. While masquerading, a field is set on the $user object, and a menu item appears allowing the user to switch back. Watchdog entries are made any time a user masquerades or stops masquerading.

Life frequently asks more of us and the same applies for employees in whichever employment sector. For teachers and nurses they know the call. As a nurse you adopt the mask of the uniform and the role. You may not actually carry the lamp, but it's there. Sometimes it helps light the way; for the public, for you. If you are a 'bad' nurse - whether your attitude put the lamp out this morning, yesterday, or several years ago -  the darkness that follows you about speaks volumes.

It prompts Prime Ministers to make announcements:

PM announces new focus on quality and nursing care

06 January 2012 12:54

A new drive to free up nurses to provide the care patients and relatives expect has been announced today by Prime Minister David Cameron and Health Secretary Andrew Lansley.

The push will see nurses spending more time on front line care in wards and other services, a senior ward nurse with whom the buck stops, patients leading on inspections and a new 'friends and family test' to show whether nurses and patients had a good overall experience, or would want loved ones needing care to be treated at each hospital.

Prime Minister David Cameron said:

“We know the vast majority of patients are very happy with the care provided by the NHS. And I’ve seen the NHS at its very best. But we have heard recently that in some hospitals patients are not provided with the level care or respect they deserve and I am absolutely appalled by this.
“If we want dignity and respect, we need to focus on nurses and the care they deliver. The whole approach to caring in this country needs to be reset. And it needs to start with this simple fact. Caring for patients is what nurses do. Everything else comes second."

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While we all play masquerade there are many levels. As a 'nurse' it's difficult (but never impossible) to play the caring, skilled, knowledgeable, patient, warm, efficient ... representative AND ensure all records are maintained, letters written, all communications logged, targets achieved, electronic records and data gathering requirements met. ... If you need a steer-clear from the stereotypical image of Angels, then you should see the faces nurses pull behind the mask trying to satisfy the audience.

That audience does not just include managers, patient representatives, inspection agencies but policy makers and politicians. Of course the latter are expert proponents of masquerade (they practice through a 4-5 year cycle).

Closer to home and the Drupal module? Well, I can't see a role for masquerade on a new h2cm website, but the thought crosses my mind of general nurses masquerading as mental health nurses; social workers masquerading as nurses. ... Although I'm playing games :-) it makes you think about what we mean by 'multidisciplinary'. To what extent, for example, is care of people living with dementia being missed because these disciplinary distinctions - silos really do still prevail? Surely the nursing issue isn't just a lack of light?

This announcement is not exactly news given what has gone before in the UK media through 2011.

What is strange is that this policy should emerge in 2012: The Alan Turing Year.

Yes, nurses DO need time to care, but perhaps we also need a test for empathy and rapport and not just intelligence?

Naive holism, Hodges' model and a lesson from NeuroLinguistic Programming

The pen is mightier than the sword.

Words are indeed very powerful, which means we should be careful how we use them.

In the mid 1980s when artificial intelligence (AI) had a temperature well above normal limits, personal studies brought me to the words that represent commands in expert system and artificial intelligence applications. The question - how might language influence our expectations of such programs? In what was a major personal project at the time (which never saw the light of day - but whose effects may be evident in the main website and this blog?) I discovered and referenced work on problems discussed by McDermott (1985).

This included the choice of mnemonics used in AI programs, with McDermott comparing the mnemonics in two systems - Planner and Conniver.

True: things have moved on - but history, history....

Planner : Conniver
GOAL : FETCH & TRY-NEXT
CONSEQUENT : IF-NEEDED
ANTECEDENT : IF-ADDED
THEOREM : METHOD
ASSERT : ADD

Upon executing 'GOAL' or 'THEOREM' into a computer 'you can just feel the power at your fingertips. It is, of course, an illusion.'

'If a researcher tries to write an "understanding" program, it isn't because he has thought of a better way of implementing this well understood task, but because he thinks he can come closer to writing the first implementation.' Ibid.

Legally, today the world is very different and yet without care extreme enthusiasm and the market may blur our vision and (rather ironically) dull our reason; McDermott observes that:

'If he calls the main loop of this program "UNDERSTAND" he is (until proven incorrect) merely begging the question.' Ibid. p.144.

I believe there is a similar lesson in terms of 'holistic care'.
As the track is swept and the starting blocks are put in place for decision making in the clinical forum - what sense are the users to make of the language used? Will eagerness to engage ("wow!") the user community cause a false start and what might the impact be?

Words are like sub-atomic particles: strange, ordered, chaotic, true, honest, noisy, quixotic.

Repeat some over and over and they become nonsensical.

Repeat yet other words over and over at the behest of those who know and they
conjoin, concatenate
to become belief-bearing,
an energetic property with a sharp edge that can turn the tide of history
(departmentally, locally, nationally and globally).

Here are (just) two reasons why holistic care has proved so elusive:

1. It is easy to add 'holistic' into care and ward/service philosophies and policies.
2. Actually measuring holistic care is not straightforward, but the measures should be specified as the word is first used - enacted. (If the service in question has someone working in a professional practice development role this might well fall to them.)

The usual outcome is what we might call 'naive holism'. The word is there in policy (for all inspectors to see). There are concerted and authentic efforts to step beyond the physical and the interpersonal domains, but there is still much to do. As for the social and political - maybe tomorrow.

If such a thing is possible an evaluation of 'holistic bandwidth' would of course need to be done at upon completion of a care episode. Maybe there is a test...?

While physicists struggle on with it - perhaps String theory can assist us? More to follow....

McDermott D (1985) Artificial Intelligence Meets Natural Stupidity, In MIND DESIGN, Haugeland J (Ed), MIT Press, London, p.144-145.
(I hope the quote is correct - old notes - and no time to check, but you have the gist).