BBC Radio 'File on Four' - DASH to Instrumentalise

Of course, I'd like to see Hodges' model applied to many purposes.

As probably posted at some point, the thought of Hodges' model being instrumentalised goes back a long way. To the time of microcomputers in fact and 'CAPA' which stood for 'Computer-Aided Patient Assessment':

Jones, P. (1986) Computing in Nursing NEWS. Computerised Patient Assessment. Nursing Times. 85: 5. Sep 3-9;82(36):63-5. PMID: 3532039

[Describes 'CAPA', a BBC BASIC microcomputer program for student nurses.]

Even before discovering Hodges' model in the late 1980s, I was sensitive about being seen to mechanise nursing and care delivery. Nursing was still preoccupied with the nursing process and individualised care. The last thing I would want is to be seen as supporting the processing of patients. The person, their social context and identity becoming lost. It was a long-term and ongoing co-author who drew my attention to Hodges' model as an instrument. Which I've considered for each and across the care domains. CAPA was simplistic, even beyond the programming language employed. A dependency score from 1-5 was allocated (it's a long time ago!) to each of the activities of daily living for a patient:

Roper, N., Logan, W., & Tierney, A. J. (2000). The Roper-Logan-Tierney model of nursing: Based on activities of living. Churchill Livingstone.

In healthcare we are trained and become accustomed to the use of many assessment tools, checklists; this includes mental health nursing and specific therapies. Emphasis, is rightly placed upon the safety, validity and hence testing of tools. Some are 'broad brushes'. Others are specific - outcomes, anger, a carer's knowledge, conviction of belief, mood, impulsivity and many more. Drift away from the original goal and purpose and problems can (predictably) ensue. Training will and must be updated, but do all assessment tools have a 'Use By' date? Hopefully there is ongoing development, version control and sustained trials and testing of the instruments themselves.

'File on Four' BBC Radio 4 this evening concerns DASH, which stands for "Domestic Abuse, Stalking and ‘Honour’- based abuse".

New citation for Hodges' model

It was a struggle obtaining a copy, as the paper is not open access, but more good news with Doyle & Jones (2013) being cited in:

Yasemin Güner, Bilge Delibalta, Melek Üçüncüoğlu, Sinan Paslı, Challenges encountered by emergency nurses in forensic case management: A qualitative study, Journal of Forensic and Legal Medicine, Volume 109, 2025, 102807, ISSN 1752-928X, https://doi.org/10.1016/j.jflm.2025.102807.(https://www.sciencedirect.com/science/article/pii/S1752928X25000083)

The above has been added to the blog's bibliography. 

The abstract reads:

Purpose/Aims: This study aimed to reveal the opinions of emergency room nurses regarding crime victims and the challenges they experience.
Design: This study was a qualitative descriptive study.
Methods: A convenience sampling method was used in the study. Data were collected through individual in-depth interviews using semi-structured questions lasting approximately 45 min. The interviews were audio recorded. In total, nine nurses individual interviews were held.
Results: The study was completed with nine nurses with approximately twelve years of experience in the emergency department. Four themes were identified: duties and responsibilities of nurses in crime victims management; maintaining well-being in challenging crime victims; education needs of emergency nurses for crime victims; and challenges experienced by nurses in crime victims management.
Conclusions: When contextualizing the findings of our study within forensic nursing theory, it becomes evident that nurses play a pivotal role in continuously informing, influencing, and advancing forensic nursing care to improve patient health, forensic evidence collection, and criminal justice outcomes. A key finding of our study was the impact of interaction with crime victims in the emergency department on nurses’ well-being. In this regard, implementing institution-supported education policies, establishing units dedicated to supporting wellbeing, and fostering a supportive organizational culture are essential measures to promote the resilience and effectiveness of nurses in this critical field.

I will read again, and reflect later in the month.

'New' citation of Hodges' model - Kennedy (2019)

This morning an alert from ResearchGate brought news of a further not so new citation of Hodges' model:

Kennedy, Harry G. (2019). National Forensic Mental Health Service (NFMHS) Model of Care. 10.13140/RG.2.2.30103.59041.

I've extending thanks to Prof. Kennedy, and have added the details to the blog's bibliography (in the sidebar). It is not as if Hodges' model played a key role in service design (care architecture?), but it is nonetheless marvellous to achieve this visibility.

This does make me wonder if there are others?

Any further news welcome.

A citation of Hodges' model IN "Excellence in forensic psychiatry services..."

McLaughlin, P., Brady, P., Carabellese, F., Carabellese, F., Parente, L., Uhrskov Sorensen, L., . . . Kennedy, H. (2023). Excellence in forensic psychiatry services: International survey of qualities and correlates. BJPsych Open, 9(6), E193. doi:10.1192/bjo.2023.578

Background

Excellence is that quality that drives continuously improving outcomes for patients. Excellence must be measurable. We set out to measure excellence in forensic mental health services according to four levels of organisation and complexity (basic, standard, progressive and excellent) across seven domains: values and rights; clinical organisation; consistency; timescale; specialisation; routine outcome measures; research and development.

Aims

To validate the psychometric properties of a measurement scale to test which objective features of forensic services might relate to excellence: for example, university linkages, service size and integrated patient pathways across levels of therapeutic security.

Method

A survey instrument was devised by a modified Delphi process. Forensic leads, either clinical or academic, in 48 forensic services across 5 jurisdictions completed the questionnaire.

Results

Regression analysis found that the number of security levels, linked patient pathways, number of in-patient teams and joint university appointments predicted total excellence score.

Conclusions

Larger services organised according to stratified therapeutic security and with strong university and research links scored higher on this measure of excellence. A weakness is that these were self-ratings. Reliability could be improved with peer review and with objective measures such as quality and quantity of research output. For the future, studies are needed of the determinants of other objective measures of better outcomes for patients, including shorter lengths of stay, reduced recidivism and readmission, and improved physical and mental health and quality of life.

<>

As the second citation  for Hodges' model from ResearchGate this month, I hope this is a trend. If I can assist any researchers, please let me know. 

While welcome, I'm not interested in being a co-author; if I can help your understanding and application of Hodges' model this is what counts.

Delighted to add McLaughlin et al. to the bibliography.

Many thanks to Harry G. Kennedy and team.

CLOSE(D) CARE: Group climate in a secure forensic setting for individuals with mild intellectual disability

This morning ResearchGate alerted me to a new paper/thesis citing Hodges' model. 

I will add this to the bibliography and post again in the new year, relating selected conceptual content of Elien's thesis to Hodges' model.

Background

CLOSE(D) CARE

This study examines associations between group climate, aggressive incidents and coercive measures in adults with mild intellectual disability or borderline intellectual functioning (MID‐BIF) of a secure forensic setting.

Method Participants (N = 248) were interviewed about their perception of group climate utilizing the Group Climate Instrument. Data on aggressive incidents and coercive measures were retrieved from the facilities’ electronic database. A multilevel structural equation model was fitted in which variability in perception of group climate within and between living groups was examined.

Results An open and therapeutic group climate was associated with lower levels of aggression within and between groups. A higher number of aggressive incidents were significantly associated with a higher number of coercive measures.

Conclusions The findings have implications for the understanding of how group climate may play a role in reducing aggressive incidents at the living group in treatment of individuals with MID‐BIF in secure forensic settings.

Elien G Neimeijer (2021) "CLOSE(D) CARE: Group climate in a secure forensic setting for individuals with mild intellectual disability." Radboud University, ISBN: 978-94-6416-713-9
https://www.trajectum.nl/sites/default/files/proefschrift_e._neimeijer_pdf.pdf

Reference [ii] "Practice in forensic psychiatry: A proposed interdisciplinary model"

Practice in forensic psychiatry:
A proposed interdisciplinary model

Expanding on the post about a further reference for Hodges' model:

Holmes, D. Perron, A. Jacob, J.D. Paradis-Gagné, É. & Gratton, S (2018). Pratique en milieu de psychiatrie légale: proposition d’un modèle interdisciplinaire. Recherche en soins infirmiers, (Practice in forensic psychiatry: A proposed interdisciplinary model). 134, 33-43. DOI: 10.3917/rsi.134.0033

Here, and on twitter I have sought to stress the limitations of the biopsychosocial model in healthcare, and I value Holmes et al. recognition of Hodges' model as politico-biopsychosocial. 

The authors also identify the structural nature of the model.

 

In comparing 'models of care' there is the question of whether Hodges' model is a model of care. As a generic conceptual framework Hodges' model can of course be used in the health care (as per its original design and creation) but it can be used to compare models of care.

Below, translated by Google are the models used in the paper.

I have altered the listing bringing the Tidal and Recovery model s together. Some I've 'mapped' in pairs, using formatting to indicate the differences.

Tidal Model

"The Tidal Model is a humanistic nursing model of recovery developed by Barker (12) with the premise that the person with mental disorder has strengths, abilities, personal priorities and a future ahead (13). This model of care, popular in forensic psychiatry circles, recognizes certain deficits of the hospitalized patient but it is especially interested in the meaning that the latter attributes to them. The sick person is the expert in his life and is therefore the one who contributes the most to his own recovery. This nursing perspective is therefore centered on the phenomenological experience (lived experience) of the patient and on the role of the staff, which is to allow healing and restore hope (12,14)."  

Recovery Model

"A popular model in mental health care, the recovery model is increasingly gaining ground in psychiatric care settings (28). The postulates of this humanistic model state that anyone, including those suffering from mental disorders, can aspire to a fulfilling future, participate in rewarding and inspiring activities, self-determination and finally, be able to live in an environment free of stigma and discrimination (29). The peculiarity of this model lies in the fact that recovery is part of a process where the person with mental illness can continue to show symptoms while being able to adapt to their condition (often chronic) and pursue their goals. life (30)."

Individual
|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

Group

recovery strengths, abilities, personal priorities deficits healing and hope phenomenological - (lived experience) personal responsibility fulfillment - life goals patient as expert personal adaptation living with x,y,z... coping strategies	place as context my future deficits signs - symptoms chronicity Institutional settings clinical - hospital
humanistic - human qualities social expectations social contribution participation - social inclusion free from stigma deficits	Institutional settings politics of recovery free from discrimination forensic deficits

<>

Integrated Practice Model

"This model was developed by Virginia Lynch, a pioneer in forensic psychiatry, and it guides the role of practicing staff in this care setting (15). There are three main theoretical foundations: 1) the fields of expertise involved (nursing, criminal justice and forensic science), 2) the health system (victim and offender, health care and forensic nursing ) and 3) the social impact (social sanction, human behavior, crime and violence) (16). According to this model, patients should be cared for using an interdisciplinary and holistic approach (15)."

Individual
|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

Group

nursing forensic psychiatry 2. health system interdisciplinary holistic OFFENDER	nursing theoretical foundations forensic science 1. fields of expertise 2. health system interdisciplinary holistic
VICTIM role of practitioners 2. health system 3. social impact (social sanction, human behavior, crime and violence)	criminal justice 2. health system

<>

Model of Nursing Interaction

"This model of care includes six categories of forensic nursing interaction with the goal of establishing a relationship with the patient: establishing and maintaining a relationship (relationship based on honesty, respect and trust), encouraging and support interactions (help the patient to recognize his qualities and use his resources), the learning of social skills (encourage the patient to do social activities and talk to others), reality orientation (help the patient patient to be aware of his way of being and of acting), reflective interactions (the perception of the patient and his problems) and the learning of practical skills (encouraging the patient to develop good lifestyle habits) ( 17,18)."

Individual
|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

Group

patient qualities, resources reflective interaction self-perception of problems reality orientation awareness of way of being and of acting	practical skills develop lifestyle skills
reality orientation learn social skills develop lifestyle skills encourage social activities talk to others	encourage and support interactions reality orientation perception of patient and problems

<>

Healthy Living Program

"This model was developed in response to metabolic syndrome and physical illnesses that may develop in people with severe mental illness (19). It includes programs related to health promotion activities such as weight reduction, smoking cessation, physical exercise, etc. It is a voluntary approach that not only improves physical health, but also independence and recovery. For the program to work in the institution and to fit into its organizational culture, the approach must be flexible and systematically maintained by the entire interdisciplinary team."

[ PARITY OF ESTEEM ] 

mental health - metabolic syndrome physical illnesses

Individual
|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

Group

independence recovery voluntary approach	(physical) health promotion activities such as weight reduction, smoking cessation, physical exercise,
independence recovery	voluntary approach for program to work in the institution and to fit into its organizational culture, the approach must be flexible and systematically maintained by the entire interdisciplinary team

<>

Holistic Model

"This model is used in forensic care in the assessment, health care and psychotherapy of patients with personality disorder (22). Holistic care includes the physical (diet and exercise), cultural, spiritual, and psychosocial needs of the patient. This model is based on problem solving, anger management and decision making. Caring is a central concept in the holistic model and is actualized in an emotional, psychosocial, constant and authentic caring response (23). It is for caregivers to be present for the patient, to respect his situation, to understand his experience and to demonstrate a desire to help."

Individual
|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

Group

holistic care personality disorder [mental] health care psychotherapy assessment emotion problem solving, anger management decision making actualized psycho-	holistic care 'caring' assessment diet, exercise health care 'being present'
-social culture holistic care 'being present' constant and authentic caring understand person's experience respect person's situation desire to help	forensic care holistic care desire to help (also exemplified in the organisation?)

<>

Good Lives Model

"This model focuses on the offense committed by the mentally disordered offender, his recovery, the promotion of personal goals, the reduction of the risk of reoffending, and the treatment of mental illness (24,25, 26). The model favors an approach based on the strengths of the patient. In addition, mechanisms of change are present, that is to say that behaviors judged to be poorly adapted are replaced by adapted behaviors when the patient is equipped with the skills, resources and support provided by the nursing staff. This model contextualizes the offense, focuses on the symptoms of mental illness while conceptualizing both as inappropriate behaviors.This model helps to better understand the relationship between mental illness and crime in order to create an individualized plan of care."

Risk-Need-Responsivity Model

"This model (27) imported from the correctional environment was adapted to the psycho-legal context by the addition of the “mental illness” dimension. It was developed primarily to reduce the risk of recurrence. Care interventions are geared towards the identification and treatment of criminogenic factors. This model is based on three major principles: the risk principle (granting the highest level of resources to the group most at risk of crime), the needs principle (identifying dynamic criminogenic risk factors and targeting them in treatment) and the principle of receptivity (adjusting programs according to the characteristics of the person: learning style, motivation, strengths, etc.) (24,25)."

Individual
|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

Group

mentally disordered (diagnosis) recovery characteristics of the person learning style (evidence?) motivation, strengths 3. principle of receptivity treatment: skills, resilience personal goals “mental illness” <-> crime recurrence individualized plan of care	1. risk principle -> resource allocation recurrence treatment 2. dynamic criminogenic risk factors  support of nursing staff
treatment [social determinants?] mechanisms of change adapted behaviours inappropriate behaviours recurrence	offense reoffending correctional environment contextualise the offence treatment principles [policy] recurrence

<>

Hodges' Health Career Model

"This model has a politico-biopsychosocial structure which is consistent with contemporary interdisciplinary practice (20); that is, it relies on a multidimensional critical approach, incorporating writings in sociology and politics, in order to understand the person in context. It is based on four objectives: measuring learning, providing holistic care, supporting reflective practice and closing the gap between theory and practice (21). This model is applicable in various clinical situations in a psycho-legal context. When this model is used as a frame of reference, it emphasizes the role of caregivers who must meet the patient's needs and focus on their problems. It also serves as a guide to assess and provide assistance to the patient vis-à-vis their physical, psychological and social needs as well as with the justice system in order to promote their recovery. The theoretical foundations call on four sources of knowledge: interpersonal, scientific, sociological and political (21)."

The PERSON in Context 

(situated)

Individual
|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

Group

INTRAPERSONAL INTERPERSONAL reflective practice conceptual structure psychological needs measure of learning psycho-	SCIENTIFIC physical needs theory-practice gap
SOCIOLOGICAL reflective practice (develop self-awareness) social needs practice-theory gap	POLITICAL justice system (needs) -legal

[ all embedded within the SPIRITUAL ]

Not just 'problems' Hodges' model can incorporate any desired stance, perspective or philosophical approach - strengths, disease, skills, weaknesses or deficits, psychosocial for example.

I am not sure about explicitly 'measuring learning, but the model can be used by learners and teaching staff / mentors to demonstrate their understanding and justify their output - formulation.

There is an instrumental potential in Hodges' model as a whole. Hodges' model can illustrate the degree of holistic intent - whether this is realised could also be indicated using the model.

Once again I am grateful to the authors for their inclusion of Hodges' model. The reference is listed in the blog's bibliography (please see the sidebar for others) which includes:

Doyle, M., Jones, P. (2013). Hodges’ Health Career Model and its role and potential application in forensic mental health nursing. Journal of Psychiatric and Mental Health Nursing. 20, 7, 631-640.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2850.2012.01961.x/abstract

Jones P. (2014) Using a conceptual framework to explore the dimensions of recovery and their relationship to service user choice and self-determination. International Journal of Person Centered Medicine. Vol 3, No 4, (2013) pp.305-311.

See also on W2tQ (with overlap):

https://hodges-model.blogspot.com/search?q=forensic

https://hodges-model.blogspot.com/search?q=justice

https://hodges-model.blogspot.com/search?q=interdisciplinary

'New' citation: "Pratique en milieu de psychiatrie légale: proposition d’un modèle interdisciplinaire."

Practice in forensic psychiatry:
A proposed interdisciplinary model

Checking through emails I missed a notification from ResearchGate about an additional citation for Hodges' model:

Holmes, D. Perron, A. Jacob, J.D. Paradis-Gagné, É. & Gratton, S (2018). Pratique en milieu de psychiatrie légale: proposition d’un modèle interdisciplinaire. Recherche en soins infirmiers, (Practice in forensic psychiatry: A proposed interdisciplinary model). 134, 33-43. DOI: 10.3917/rsi.134.0033

This is very welcome, even though in December 2021, I am 'late to the party'. This it seems is how news of potential additions to the bibliography are bound to arrive, which is a bit frustrating. It would be marvellous to learn of a project much earlier - while the work is 'live'. Not to jump on-board as a co-author necessarily, but to share the dynamism of work-in-process.

I continue to take encouragement from the fact that researchers appear able to find, understand and apply Hodges' model in their respective theoretical, practical and work context.

This is rewarding in itself so many thanks to the authors.

If I can access the English copy I will post again with any observations and comments that arise.

Translated by Google:

"Hodges' Health Career Model

This model has a politico-biopsychosocial structure which is consistent with contemporary interdisciplinary practice (20); that is, it relies on a multidimensional critical approach, incorporating writings in sociology and politics, in order to understand the person in context. It is based on four objectives: measuring learning, providing holistic care, supporting reflective practice and closing the gap between theory and practice (21). This model is applicable in various clinical situations in a psycho-legal context. When this model is used as a frame of reference, it emphasizes the role of caregivers who must meet the patient's needs and focus on their problems.It also serves as a guide to assess and provide assistance to the patient vis-à-vis their physical, psychological and social needs as well as with the justice system in order to promote their recovery. The theoretical foundations call on four sources of knowledge: interpersonal, scientific, sociological and political (21)."

In comparing several models of care please note how the authors here recognise how Hodges' model is not just bio-psycho-social; yes - it is politico-biopsychosocial.

See also on W2tQ (with overlap):

https://hodges-model.blogspot.com/search?q=forensic

https://hodges-model.blogspot.com/search?q=justice

https://hodges-model.blogspot.com/search?q=interdisciplinary

H2CM bibliography: New reference in "The Psychology of Arson"

I have only just caught up with a new addition to the bibliography for Hodges' model (please see the side bar).

Abstract: key points

• One in ten patients in secure mental health settings have a conviction for deliberate fire-setting.
• This chapter views the issue of inpatient care and management from a forensic mental health nursing perspective. 
• Hodges’ Health Career – Care Domains – Model (HCM; Hodges, 1998) is used to provide an overview of the political, biological, psychological and sociological aspects of care and management.
• Nurses can deliver and/or support all aspects of care and treatment and have particularly significant roles related to management of relational security and recovery-oriented practice. 
• The HCM can be usefully supplemented by a firesetting specific model to enhance nursing assessment.

Dickens, G.L. & Doyle, M. (2015) Mentally disordered firesetters in secure mental health care: a forensic mental health nursing perspective (Chapter 17) In, The Psychology of Arson, 1st Ed., (Eds.) Doley, R.M., Dickens, G.L., Gannon, T., pages 260-275. Oxford: Routledge. ISBN: 978-0-415-81069-2

Agnostic qualities in Hodges' model

In the previous post I highlighted "Holistic approaches to learning are agnostic as to method." 

I added that there would be more to follow as Hodges' model can be viewed as agnostic on several levels. The following is taken from a paper on Hodges' model and its application in forensic nursing:

Hodges’ model claims to be person-centred and situated (Jones, 2008). What exactly does this mean for forensic nursing? The utility of Hodges’ model lies in it being agnostic. By ‘agnostic’ this means that the model is not dependent upon, dedicated to, sanctioned by, or owned by any particular discipline (even nursing). It was not designed with a particular media, clinical setting, situation or organization in mind. It is true, however, that the model was formulated within academia and health and social care, being taught and applied by community mental health nurses, learning disability and health visiting students. Apart from the history and universality of the model’s cruciform structure and its inherent 2 x 2 matrix form [often referred to as a Johari window (Luft and Ingham, 1955)], the model is also culturally neutral. This is an essential requirement to reflect and enact nursing values and codes of conduct (Nursing and Midwifery Council, 2008).

Doyle, M., Jones, P. (2013). Hodges’ Health Career Model and its role and potential application in forensic mental health nursing. Journal of Psychiatric and Mental Health Nursing. 20, 7, 631-640.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2850.2012.01961.x/abstract

Update: Drupal 7.14 + 8 and papers

My laptop is four years old next month and a refurb at that. The DVD and webcam no longer work. The Apple store in Manchester helped me update the OS to Snow Leopard and I'll catch up with the rest of the cat pack soon.

It seems I've 'summer cleaned', deleting files and older Drupal installs, the rain making me think it's April. Drupal 7.14 and version 8 are insitu. Drupal 8 would not install, MAMP's version of PHP being too old. I'm sure I checked the site, but must have missed the MAMP update which is now running. Trying to resolve this issue one really useful find c/o PHPNW is the package manager HomeBrew.

This weekend I'll upload my first Drupal test site. It's for a family member not a client, but this does not mean that the passing of time - months, years... has gone unnoticed. It's a pretty basic site, nothing elaborate. Three pages: About me, DJ-ing, and an Enquiry form. The enquiry form has been created using the Webform module.

I want the user form to be clean, without the tab options (view, edit...) being displayed. I removed them using Tab Tamer. There may be an easier way to do this - over riding, for example but it is all learning. The development effort is still not helped by picking Drupal up, putting it down...

The 'client' then wanted comments added to the form. Searching around the content types, module configurations ... was getting frustrating, a search brought me to the Drupal community and voila: success! Comments added to form. User requirements have shifted further ;-) the Sound Engineering page is to be reinstated. At least it's just a case of re-enabling it (I think) and tweaking the menu. This experience reminded me of tips from local Drupal meetings and Drupalcons: keeping a record of changes. If a new h2cm site is to be created then a log will be essential. If there is a new version of the DJ site then I will definitely use a responsive theme.

Drupalcon Munich is fast approaching. I've checked the schedule and created my personal itinerary. With Drupal 8 on the horizon for late 2013 the core conversations should be popular. I'm really looking forward to it. There are no BoFs (birds of a feather) sessions planned as yet on education or mental health. Anyone interested? I'll see if I can submit something.

On the papers front; when the details are known the bibliography entry will be fully completed:

Doyle, M., Jones, P. (2012-13) Hodges’ Health Career Model and its role and potential application in Forensic Mental Health Nursing, Journal of Psychiatric and Mental Health Nursing.

I am still keen to explore the possibility of a symposium session next May as per previous posts. Likewise if there are any teaching* opportunities in Australia to share Hodges' model and help to fund the (ad)venture please let me know.

*It's not so much that I teach, but that students learn.

Rooms with a View (and without) ...

There are times ... when to understand body, mind - and the things that people do to themselves and others - we need to consider the four care domains.

Then we can appeal to the fifth. ...

Carer's support evidence / measures and end of life care

The following e-mail was received this week from (Prof.) George Kernohan and includes correspondence with Mary A. Waldron, Research Assistant, University of Ulster (thanks to Mary for confirming the reference).

My responses to George's points are right justified, italicised.

<->

Peter,

I am beginning to find examples of Hodges’ model every day now.

Once you adopt the model as a framework George it does tend to frame everything,
so I am not surprised at your finding. Maybe there is a paper there too...

Today we had a second research meeting to consider a (more) rigorous attempt to evaluate the provision of ‘support’ to carers of people undergoing palliative or End-of-Life Care (EOLC). An area of care with a dearth of evidence. So we looked at one review from Grande et al. (2009). They say that:

There has already been considerable research identifying carers’ needs in EOLC. These include psychological support, information, help with personal, nursing and medical care of the patient, out of hours and night support, respite, domestic and financial help.^9,10,16–21 There is also a large body of research into adverse effects of care-giving, such as anxiety, depression, stress, strain, fatigue and mortality.^22–24
Given this strong evidence base, any further investigation into the prevalence of needs and adverse effects should mainly focus on under-researched groups to ensure that future interventions are sensitive to their specific concerns. This includes carers of patients with conditions other than cancer, including neurodegenerative disorders,²⁵ respiratory²⁶ and cardiovascular diseases,²⁷ to help us understand how differences in disease trajectories, awareness of the terminal nature of the disease and available support²⁸ translate into different carer experiences. Although carers of patients with dementia have been extensively researched, little is known about their needs during patients’ final phase of life.⁹ p.340.

(The numbers refer to references by Grande et al., I have extended the quote used here).

Thanks for this paper George (and Mary) which I will read in full.
I extended your quote to encompass some additional interesting ideas.

To move toward a plan for a more rigorous evaluation, I would like to use a simple framework: here we go!

I think I will be suggesting Hodges’ Health Career as a possible model.

:-) ! If I can support you in this George I am pleased to help.

This could provide a framework for all carer-focused interventions in a broad way. As always, it would imply that carers need to have their needs addressed in terms of science, sociology, politics and interpersonal needs. As I see it, the first step would be to ‘map’ the carers’ needs onto that framework (from publications, if necessary from carers themselves). The basic idea (I think) is that care should address the four quadrants:

• Science: (carer’s physical needs, information, instruction)
• Political: (policy that enables care for carer, finance, allowance)
• Sociology: (recognising that people need people, networks and “sharing” groups, story telling/hearing)
• Interpersonal: (psychological support, prevention of anxiety & depression)

Have you any thoughts or guidance on this “mapping exercise”?

Goodness, that's quite a question!

Plenty of thoughts George but not sure how meaningful ....
Basically, since a community mental health project in 1990s
I have always considered (as per standard approach of course) that a toolkit of measures are needed. Even when we start from that most basic of distinctions between demand and supply.

As per your approach if h2cm is considered as a circle, a spectrum -
(sometimes we must circle the square)
then (if holstic) the adopted measures should cover all the domains:

Political: (outcomes, carer, patient satisfaction, financial assessment (means testing), respite care frequencies, reviews)
Interpersonal: (mood, coping ability, anxiety, depression, sleep, HoNOS)
Sciences: (pain, general health scales, care complexity (measures?))
Sociology: (dedicated carer assessment tools, sociability - social network size, psychosocial measures... there are many out there)

George, I realise the above is a ragbag collection but - like yours - these are dimensions which can (must) be reduced. Now there is also emphasis on this area post Darzi and the 'new' quality agenda.

This will serve (and is serving) to emphasize the distinctions between measures:

Objective - Subjective
Quantity - Quality
Staff administered - Self (Patient, Carer) administered
Global/general - condition specific
Service centered: Primary care - Secondary care

While it is easy to spin dichotomies,
the NHS must (constantly) focus on this area whatever the policy emphasis:

NHS Information Centre: Measuring for Quality Improvement

NHS Information Center: What is happening on indicators for...?

NHS Inst. for Innovation and Improvement: Quality and Service Improvement Tools

Earlier this year I contacted the NHS-IC [enquiries at ic.nhs.uk] regards additional measures of quality suggesting that the health career model bears due consideration (research).

Mental health services (and others?) have recognised how the measures they use can be a chaotic, personally selected, preferred, legacy-mix of assessment tools. Dictated by Senior Nurses, Consultants, Senior Management and not the evidence base. Now these are assured (are they?) with purposed selection (a task worthy of an 'away day') and then supported with regular in-house training.

Last month Anne-Marie Osbourne-Fitzgerald, Clinical Development Nurse, with (her) Clinical Manager, Denise Banks (Cygnet Hospitals), met Michael Doyle (Univ. of Manchester & Edenfield Unit, Prestwich Hospital) and I one evening at the Trafford Center in Manchester. Our two hour+ discussion covered the health career model, documentation, approaches to formal assessment and future plans (aspirations!). In the time available we obviously only scratched the surface, but Mike and Anne-Marie brought along examples of their paperwork.

Mike demonstrated how the health career model can be used implicitly or explicitly. At the Edenfield Unit the domains are being used individually to make up what is a standard A4 portrait form. The model informs their existing documentation; rather than the explicit form of the h2cm with the 2 x 2 matrix.
(I have a MS Word version of the latter and must update this to other formats).
Legally, as we know if it is not written down, recorded then it did not happen.
Educationally however, the objective is also to get students - practitioners - to think - before they do.

Anne Marie's documentation example at Cygnet Hospital included The Recovery Star:

http://www.mhpf.org.uk/recoveryStarApproach.asp

As you consider the star's points against the domains of the health career model - where in the model are you?

Can this provide another means to define 'care pathway'? A way that is not masked, hiding behind political, policy rhetoric (and really service-centered)? There are without question some excellent tools available, so care needs to be taken not to re-invent the wheel - hence your literature search. In some tools the effort and engagement of patients, carers and the public is exemplary. It seems what is needed is a hybrid solution. There is no single measure.

It may not sound scientific, but the complexities of care mean that academics, clinicians and managers must resort to a pick'n'mix approach. There is a battery of evidenced tools each with their history, application context and issues log (Why not? Lack of the latter might denote that such tools are no longer in development / review). As a clinician also involved in training, managers need to listen and make some tough operational decisions. The comms 'traffic' between clinicians, their managers, and senior managers needs to improve even more. Since, just using the above as an example, the STAR approach may find us on a ramble in the humanistic domains, the constraints of the mechanistic domain prompts the clinician's to ask:

"If you want me to use this assessment tool, what other thing do you want me to put down?"

As we are all aware: There is only so much time in a day, week, month, quarter. ...

In follow up emails I directed Anne-Marie to -

http://www.p-jones.demon.co.uk/contexts.htm

If you scroll down there is some discussion and graphics I did quite a while ago. This deserves revision as per the rest of the website, but the ideas are there I believe which can inform your project George?

Back then - and here on W2tQ I have been trying to demonstrate the wide range of contexts to which the health career model can be applied. In our meeting that evening the well established Tidal Model was also noted. This has of course benefitted from specific development, as per research that has produced audit and evaluation tools (Stevenson, et al. 2002).

It might make a useful reflective article – or at least a conference presentation. Ideally it would lead us to a measurement or observation approach ...

I would relish the prospect of a paper George, or a conference presentation. Not just contributing as a co-author/presenter, but supporting and enthusing new authors. The 21st century belongs to our students. Hodges' model can act as 'stellar' nursery not just here in the UK and EU, but globally. And not just in our respective disciplines (mental health, palliative - end of life care, forensic nursing care), but in informatics - conjoining and championing the need for socio-technical perspectives.

In addition to the above and thinking before they do, all health and social care practitioners must be able to reflect after.

As one of the original purposes for the model in my initial interviews with Brian Hodges (1997-98), research work addressing these are much needed.

This conceptual framework can offer much in case formulation, evaluation, clinical supervision, patient, carer and public (health) engagement.

[In short -] Can we measure Hodges' model?

George K. (Prof.)

You started with a big question George and similarly here at the end.
We have to be able to do this. In the first instance taking apart your question - there are clearly several questions here:

PRACTICE:

Above you noted that:

This could provide a framework for all carer-focused interventions in a broad way. As always, it would imply that carers need to have their needs addressed in terms of science, sociology, politics and interpersonal needs. As I see it, the first step would be to ‘map’ the carers’ needs onto that framework (from publications, if necessary from carers themselves).

It would be interesting to consider the formal process and practice of dementia care mapping against Hodges' model. Perhaps the approach you seek is something similar? If carer's make use of self-assessments these e-documents might act as an input for text analysis tools? If appropriate you could also weight certain items according to the priorities of carers? This would build on other carer research adding validity to your 'final' objectives.

Carers and clients (patients, service users) can with due explanation, appreciate the health career model. The model has a role to play in health education. I can well imagine a proforma similar to the Recovery Star example above, but purposed for carers and underpinned with the health career model. We also need to remember the spiritual domain, which is collective.

Ultimately George, your question concerns our ability to measure holistic, integrated, person-centred, multidisciplinary care and to state the obvious: there is no single measure to do this. Several tools and approaches gathered within a conceptual framework might however provide an environment favourable for a hybrid measure to emerge - literally a cycle?

THEORY:

In the paper you referred to George - Grande. et al. (2009) state:

In parallel with the lack of empirical evidence, there has been a lack of theoretical and conceptual models for when and how support provision in EOLC should improve carer outcomes. To guide further research, palliative care may here benefit from drawing on models within other fields, such as gerontology, sociology or psychology. p.341.

I am biased, but reading the paper the potential of the health career model as a high level tool is convincing just from a 'disciplinary cross-match'. Intra-, interdisciplinary, metadisciplinary and transdisciplinary perspectives could be a focus. This in addition to the specific knowledge and practical domains of sociology and psychology and as the authors note models therein. I forget the reference at the moment (and will check), but I recall carers / family units being framed in terms of strengths and weaknesses. That is, events, characteristics and relationships impact on a family with either additive, subtractive or neutral effects. This would seem applicable here?

While Grande et al. (2009) note that the (informal) carer's role is hidden (and is routinely described in this way) I wonder if in palliative care there are other dimensions that accentuate this 'hidden, covert' role?

The politics of potential death and actual dying may be another factor the health career model can help illuminate in a constructive, enabling way? Health care, patiency, sick roles, caring are always mediated by 'politics'. Hence the need for a political domain in any conceptual framework that Grande, et al. may consider. On a negative front, the model might also illustrate alienation and related concepts?

In conclusion!

Thank you so much George and Mary for my being able to share your initial thoughts here and respond with some of my own. I hope this helps you take your work further? There may be a few points to follow, which I will add and as you have noted above there is much that could be done to take this further.

Peter J.

From: Waldron Mary [mailto:MA.Waldron at ulster.ac.uk]
Sent: 06 June 2010 17:49
To: wg.kernohan at ulster.ac.uk
Subject: Carers Support Evidence

George,

Jury's still out on the effectiveness of support interventions and programmes which support carers in palliative care. Not enough research. Lack of evaluation, lack of rigour, no conclusive research, but lots of policy advocacy of carers support and addressing of needs. Sample of lit attached.

Mary A Waldron,
Research Assistant,
School of Nursing,
University of Ulster.

Many thanks George and Mary for your ongoing interest, and to Anne-Marie, Denise and Mike.

Reference:

Grande, G. et al. (2009) Supporting lay carers in end of life care: current gaps and future priorities, Palliative Medicine, 23: pp. 339-344. DOI: 10.1177/0269216309104875

Stevenson C, Barker P and Fletcher E (2002) Judgement days: developing an evaluation for an innovative nursing model. J Psychiatric and Mental Health Nursing, 9(3), 271-276.

Stellar nursery image
My source: http://media-2.web.britannica.com/eb-media/60/21260-004-3C62CA58.jpg

Paper: The health career model in forensic nursing

The other week a paper was submitted to a journal on the application of Hodges' model in forensic nursing.

I am really pleased to have worked on this as a co-author and to find the health career model proving its relevance and value in such a challenging care environment.

Basically we divided the work and the paper as follows:

• Introduction to Hodges' model (new material);
• Explanation of why the model is relevant in forensic mental health services;
• Applying key principles of theory and practice of forensic care to each care domain;
• Discussion, recommendations and future directions.

Of course, this is just the 'submission' stage, so I will share news and details here in the near future - for now it's fingers x'd! If you believe the above 'content formula' might be useful to you as a publication template please do get in touch: h2cmng AT yahoo.co.uk

CARE: Whether NHS or Social Care ...

C	A
R	E

Whether -
NHS or Social Care^*
what
C.A.R.E.
is crying out for is a
universal, shared, holistic and wholly integral conceptual framework.
Then and only then will the currencies^# of care be
transferable, translatable and transforming!

* Private, 3rd sector, religious order, or social enterprise ...
# Currencies does not just refer to finance.

'Problem patients?' 2 - Appease me do (not)

Many of the aspirations of nursing are just that - aspirational.

Appeasement and other similar 'power' associated concepts helps explain some of the appeal of Hodges' model - with its inclusion of a POLITICAL care domain. The needs of the ONE (interpersonal care domain) are diagonally opposed by the needs of the MANY (political care domain).

Just because I may approach someone (*evidently*) abusing medication / alcohol, over-eating, risk taking ... does not mean I am prepared to continue to nurse them and hence support them in that behaviour. Attempts to engage can be made and (must be) documented, as subsequent referrals and care will build on those care encounters. There is a marked difference between those individuals above who are often socially excluded, risk takers and people who are preoccupied with their health and mental health state. (Are such people stuck in the 'sick role?) Such patients may well seek new drugs and then instantly question the medication they are taking, never satisfied, they may query their care record and care while in hospital by virtue of their personality and anxieties.

I can reject negative behaviours and attitudes, but not the person. As a member of the health care team I can explain clear terms for future engagement should the patient wish. At the end of the day we constantly review: do they have mental capacity and to what extent does their behaviour present a risk to themselves, or others...? There is also a role for specific care management to be effected, to screen and prevent people reaching emergency services when this is repeated and unnecessary. The combination of some conditions such as long term respiratory problems and anxiety can create acute management problems, both for the individuals concerned, their family carers and care providers.

People do have choices to make, and so must take responsibility for how they exercise those choices.

Crucially this also needs to be explained to referrers - e.g. general practitioners / family physicians. For effective care management the inclusion of paramedic, crisis, social and intermediate care services in care management communication and coordination is also essential.

So, there is absolutely no need for a "current model of appeasement based care".

(This is a wind-up - surely? If not I am available for career advice.)

Yours truly and the patient's (even if it hurts),

Peter Jones

'Problem patients?' 1

Nurse Philosophy list

Forensic Nursing: bio-psycho-social (political) steps

I've been searching for a definition of forensic nursing and came across this by The International Association of Forensic Nurses (IAFN)…

“the application of nursing science to public or legal proceedings; the application of the forensic aspects of health care combined with the bio-psycho-social education of the registered nurse in the scientific investigation and treatment of trauma and/or death of victims and perpetrators of abuse, violence, criminal activity and traumatic accidents.”
IAFN 2002

While seeing bio-psycho-social in the definition comes as no surprise - the list of areas, situations and contexts that forensic nurses may work in is enlightening:

• Interpersonal Violence
• Forensic Mental Health
• Correctional Nursing
• Legal Nurse Consulting
• Emergency/Trauma Services
• Patient Care Facility Issues
• Public Health and Safety
• Death Investigation

In writing about the relevance of Hodges' model in this field there is the assumption that forensic nursing is specialized, but built - of course - upon fundamental nursing principles and values. These are carried forward in forensic nursing theory and practice - Beyond Tradition, Advancing Humanity -  as the IAFN slogan ably puts it. Being reminded yesterday of mental health law (always a good thing!) in training on Mental Health Act 2007, I can see just how well Hodges' model can support the early bio-psycho-social steps of the nurse learner.  Then if students go on to specialize in forensic care, the model's political care (knowledge) domain will continue to serve them well.

Hodges' model: publications

The book chapter for Radcliffe Publishing is now in the hands of the editor. This is great step forward for Hodges' model (and me) in that the text considers the model within substance misuse care and services. To my knowledge the only other book chapter is that of Brian Hodges' in Hinchcliffe (1989) [please see the bibliography lower right].

The next project entails me completing my half of a paper on the application of Hodges' model in forensic nursing. My contribution introduces the model (with new text) to a forensic nursing audience and highlights why h2cm is of relevance to this very challenging specialised field of nursing. This is also a significant development being yet another clinical example and a co-authored effort. Collaboration with other people interested in and actually applying Hodges' model is definitely the way forward.

There are other topics that in championing h2cm would hit the sweet spot:

• Continuing the current vein - papers on clinical applications for the model in mental health, learning disability and health visiting. These are areas in which the model was first taught and originally applied. 

• The four original purposes for the model also compete for attention:

1. supporting holistic theory and practice;
2. reflective practice;
3. bridging the theory - practice gap;
4. curriculum development.

On that last theme, I need to type up a review of a book on curriculum development in nursing that will be featured here shortly. In the meantime if you have an essay, case study to complete, please bear h2cm in mind (and paper). ...

Can YOU add to the H2CM bibliography (now listed on W2tQ)...?

PJ

For readers not already aware, yesterday I started adding a bibliography to the blog. It is listed in the side-bar.

Links are included if applicable and these have been checked. I can supply electronic copies of most of these papers if you wish.

There are two publishing projects in process that are closely related to each other, covering substance misuse and forensic nursing.

On the forensic nursing front just over a week ago I met and greatly enjoyed speaking with -

Dr Michael Doyle
Nurse Consultant, Professional Lead & Honorary Research Fellow
Greater Manchester West Mental Health NHS Foundation Trust
Edenfield Centre
Prestwich
Manchester
M25 3BL

Apparently, Hodges' model is used and has quite a history at the Edenfield Centre. So Mike and I are working on a paper we will submit to a journal before the end of the year. More on this to follow.

In the hope that Erdos-Bacon Numbers might work for me, if anyone reading this has contact with community mental health nurses in the Isle of Man please get in touch. I understand they have used the model in the past.

Finally, should you be interested in applying Hodges' model in your nursing, social care, education or informatics theory / practice, do let me know h2cmuk @ yahoo.co.uk. I would be pleased to provide some paper - electronic resources and advice as needed.

August! Great Drupalcon soon!

Best regards everyone,

Peter J. (and yes that is me up there)

TEMSS - Therapeutically Enhanced Medium Secure Service for Women [II]

Dear Rachel (Ms Magee)

Delighted to help you and well done on picking out Hodges' model. It sounds like an exciting time for you personally being newly qualified and working on a new unit.

Apart from several occasions as a student (late 70s at Winwick Hospital) and more recent liaison through my Trust's NHS Care Record Service Project I have not worked in forensic/secure mental health services. So what follows is a very generic over view. That said Hodges' model is more than an out-liner - brainstormer tool. As your experience grows the model will grow with you and your clients if it is appropriate to share it with them. Anyway, here are some initial thoughts a real mish-mash running through the care (knowledge) domains in turn (with some repetition).

If you wish to develop and elaborate on what follows, casting a distinct TEMSS light on each care domain I'd be happy to place your prioritised version in a graphic (with you duly ack.)

intra-INTERPERSONAL
Screening on admission. Existing psychic 'injuries'.

An·a·gram: 'secure' = 'rescue' .....

Life history, experiences +ve/-ve (including hospital care), skills, strengths, beliefs, mood, expectations, RISK behaviour, personality, psychological reactions to situation (admission, secure environment, diagnosis, prognosis, treatment - psychotropics, locus of control, helplessness, motivation, family contact...), specific, individualised - person-centred care. Thought disorder? Attribution. Risk - self-harm, harm to others, self-neglect. Psychological dependence. Intelligence. Literacies: 3Rs, visual, social, information. Boredom, Mental capacity. Cognitive functioning. Religious beliefs. Personal skills, strengths, interests. Education - access to training. Response to stress - existing coping mechanisms. Sleep. Attitudes. Sexuality. Biopsychosocial influences PMT (sorry don't wish to seem sexist!)? Stress-vulnerability. Biases, prejudices. Orientation time, place, person (not just older adults).
(YOU as a nurse are also in this domain - your skills, control and restraint, anticipation of needs, observation, empathy, self-awareness, non-judgemental, bias etc....) Assessment tools. My care plan. 'personal' time. Quality - therapeutic time if used.

SOCIOLOGY
Family, pressure on existing - new relationships, spouse-boy/girlfriends, socialisation into the 'secure' environment, dependencies - children / pets. Observation. Group activities. Group therapies. Routine. Co-operation. Team work. Leadership. Status, stigma, respect. Communication. Social skills, Assertiveness. Media - papers, radio, TV. Qualitative research - client narratives. Demographic profiles - catchment areas - deprivation indices.

SCIENCES
Screening on admission. Existing injuries. Access to GP, emergency services if needed. Physical characteristics, height, weight - BP, temp, bloods, mobility. Evidence based care? NICE. Drugs, side-effects (+ substance misuse / alcohol), physical effects of addiction, physical environment - lighting (on-off [fade]), noise (acoustic) signature, colour, architecture (sharp corners vs curves), physical health problems, trauma. ADLs. Assessment toolkit - what's in yours? Nursing (care) process. Hygiene, Domestic services. Infection control. Physical space allocation. Multidisciplinary assessments - occupational therapy, physiotherapy, psychology, pharmacist. Unit viewed as a system - ecology. Complexity within TEMSS. Literature review. Site visits / conferences. Learners. Staff course study opportunities. Academic partnerships. Quantitative research. Triangulation. Statistics. Data gathering processes. Geographic profile of referrals.

POLITICAL
Human rights, policies, protocols, GP service provision, right of appeal as relevant, 'disciplinary constraints', compliance-concordance, 'offence' category. Client space - privacy / dignity. Access to therapies, rehabilitation, training opportunity, AUTONOMY, ability to exercise choice, institutional 'rules' make-up, clothing, bathing, kitchen, toilet facilities, dignity and privacy, 'unwritten' rules - bullying - vulnerable adults, abuse, financial, sexual, physical. Inspection - Commissioners - accountability. Referral process-pathway. Thresholds, waiting lists? Travel distance - regional resource. Transport links - visiting times. Cost of fares. Staff establishment. Health & safety rules. Disability. Care transitions. Learning disability. Early onset dementia. Ageism (other '-isms') RECORDS. CPA. Community Team. Qualified-unqualified staffing. Patient-relative groups. Service user representation on management. Academic links. Visiting. SAFETY - patients-staff. Serious untoward incident reporting. Translation. Advocacy - short-long term. Other agencies - Social Services, third sector voluntary partners? Philosophy of care, OUTPUTS vs OUTCOMES? 'contracts', Mental Health Act, appeals, hospital managers. Politics of care. Psychiatry in Dissent. Audit, data collection, IT systems. Access to REPORTS - INTELLIGENCE "How are we doing?" "Where are we going and is that the right way?" Your involvement - engagement - in these processes. Client - carer - public involvement. Finance budgets - (unit budget - resources), staff support / supervision. Energy use. Recycling. Client abilities with finances / debts. Homelessness. Re-housing. Existing tenancy. Opportunity for (regular) TEAM BUILDING ;-) Innovation and creativity. PDP - KSF. Targeted issues: Managed care. Personality disorder....? Professional associations, groups:
http://health.groups.yahoo.com/group/forensic-psychiatric-nursing/
No group for TEMSS for women? Over to you! .....

As you can see the model is high level. It does not DICTATE how your unit is run, what therapy is undertaken. It can help as an aide memoire prompting you and your colleagues to systematically consider all the care domains according to the context-situation and can help ASSURE an holistic assessment and evaluation.

The model can also be used to help explain problems, issues and their solution - or realistic outcomes to clients and their families. So the model doubles as an educational resource - very helpful to engage the INDIVIDUAL or a GROUP (family). You can do this EXPLICITLY using paper or flipchart for example, or implicitly with you using the model mentally as you go along...

By including a POLITICAL domain Hodges' model is ideally suited to your speciality - in fact POLITICALLY and SOCIALLY there are 'nested' issues within your 'secure care' context: gender, ethnicity, equality and equity, public attitudes, institutionalisation, citizenry, public involvement....

This blog includes many labels (on the right hand side) I will also add 'secure services'.

Rachel - I noticed on your organisation's website there are the names of the wards and address - there's a space to fill there...

Good luck, hope this helps and thanks again for your interest.

Best,
Peter