Descartes - alive and well ...

... within the Incident Reporting System

'Policy guidance on recording patient safety events and levels of harm 

This guidance is for users of the new Learn from Patient Safety Events (LFPSE) service, to provide context and guidance on selection of appropriate categories when recording incidents. It focuses on which Event Type is appropriate for different circumstances, and how to select the most appropriate options for the Levels of Harm categorisation required within Patient Safety Incidents.'

Previous harm grades

No harm

Low harm

Moderate harm

Severe harm

Death

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group-population

New psychological harm grades No psychological harm Low psychological harm  Moderate psychological harm Severe psychological harm n/a	New physical harm grades No physical harm Low physical harm Moderate physical harm Severe physical harm Fatal

Q. 'n/a'. Discuss.

CPD reading.                      

Book TSR ii - Mental illness/health: History, process and progress

As posted yesterday through a book review, I developed an awareness for the role of process much earlier than previously thought. It wasn't Enid Mumford's work on the benefits of a socio-technical approach to successful deployment of information systems. I only discovered this well after the advent of home computing with the ZX81 and BBC micro 1981-1995.

It was 1978-79 to be more exact; on an admission ward during my three year student Registered Mental Nursing course at Winwick Hospital. On first recollection, I thought it was a clinic, with patients coming in for Clomipramine (Anafranil) infusion on to the ward. As students on placement we were allocated to support the clinic, completing regular observations, including pulse and blood pressure. Clearly, it was a long time ago. There is a paper (paywall), quite a significant one for me:

O’Flanagan PM. A Clomipramine (Anafranil) Infusion Unit. Journal of International Medical Research. 1973;1(5):375-381. doi:10.1177/030006057300100519 

I remember this Consultant's name being mentioned, but this was before my time(?). From the paper's first - accessible - page I can see the patients involved were actually in-patients. Which given the procedures, safety, observation makes better sense. There is reference to a film, in a hospital newsletter 'The Standard':

'Anafranil Film

In response to the interest shown in the film on Anafranil Infusion, Dr. P. O'Flanagan was present in the In-Service Training Room on Monday, October 29th for a second showing of the film, and to answer any questions from the audience.'

https://winwickremembered.org.uk/mags/mag316.htm

I wonder if the film is archived somewhere?

It isn't a surprise to see my former Community MH manager and friend David McKendrick listed on the Publications Committee. I do miss David - a great mentor!

In the previous post about 'The Sleep Room' I contrasted the mind-body dichotomy. In terms of evidence on 'both sides' of this divide, many people have made the observation of how you can see a broken arm, or leg, and other physical ailments, but mental health issues are often not obvious:

Powell J, Clarke A. Information in mental health: qualitative study of mental health service users. Health Expect. 2006 Dec;9(4):359-65. doi: 10.1111/j.1369-7625.2006.00403.x. PMID: 17083562; PMCID: PMC5060370.

The evidence-base of general medicine - physical health and psychiatry must be dynamic. The volume of publications bears testimony to the relentless change across all the sciences, research, technologies, knowledge, theory, practice, management and policy. On Twitter there is constant 'debate' between psychiatry and anti-psychiatry. 

Studies of intravenous clomipramine continue, the intervention much changed from the 1960-70s:

Fallon BA, Liebowitz MR, Campeas R, et al. Intravenous Clomipramine for Obsessive-Compulsive Disorder Refractory to Oral Clomipramine: A Placebo-Controlled Study. Arch Gen Psychiatry. 1998;55(10):918–924. doi:10.1001/archpsyc.55.10.918

Persson M-L. Adler Mats y Hetta J. Pulse Intravenous Clomipramine as an alternative antidepressant treatment to ECT: A pilot study. Eur. J. Psychiat. [online]. 2007, vol.21, n.4 [citado 2025-04-07], pp.263-267. Disponible en: <http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S0213-61632007000400003&lng=es&nrm=iso>. ISSN 0213-6163.

Karameh WK, Khani M. Intravenous Clomipramine for Treatment-Resistant Obsessive-Compulsive Disorder. Int J Neuropsychopharmacol. 2015 Jul 28;19(2):pyv084. doi: 10.1093/ijnp/pyv084. Erratum in: Int J Neuropsychopharmacol. 2016 Apr 27;19(10):pyw031. doi: 10.1093/ijnp/pyw031. PMID: 26221004; PMCID: PMC4772819.

Perhaps, someone can please enlighten me? Given the time between William Sargant's practice, and today how much more do we know? We know the gap can't be fully closed (phenomenologically?), but has the evidence-gap been reduced? What are the evidential mile[Km]stones in psychiatry - mental health nursing? What are 'the standard' measures? If we look at a model that is bio-psycho-socio-political, what difference might this make, to the 'debate', theory, practice, research, management and politics (policy)? 

'Woke' is a tainted word these days, but in mental health care and nursing we all need to wake up and in a safe space.

NHS management accountability

INDIVIDUAL

|

     INTERPERSONAL    :     SCIENCES               

HUMANISTIC --------------------------------------  MECHANISTIC      

SOCIOLOGY  :   POLITICAL 

|

GROUP

NURSING ACCOUNTABILITY	NURSING ACCOUNTABILITY
NURSING ACCOUNTABILITY^	Managers accountable? It's about time!* Nurses have been here for a long time. You're still not listening though ...

An insightful meeting without the insight of the largest safety critical profession seems more of an echo chamber
Assume #nursing not required to deliver the winter plan. https://t.co/8fHSACVLtf

— Prof Alison Leary 💙#ProtectNurse (@alisonleary1) September 13, 2023

*Assuming NHS managers become subject to regulation and can also be held to account.

^Yes, spiritual too.

Many nurses may not want to acknowledge or contemplate the 'politics' of health. They respond quickly: It is not why they came into the profession. But, in practice and theory you / we cannot avoid it. In nurse-patient encounters, it is ever-present; it is the other / shadow encounter.

"Models, Theories and Concepts" c/o Smith (1994). Plus ça change ...

"Whilst the impracticality of unified approaches has been noted for some time (McFarlane, 1976), it is still considered that many theories, in their efforts to explain everything, succeed only in explaining nothing (Draper, 1990). Therefore, as Kenny (1992) points out, the use of theories and models in nursing has resulted in sweeping generalizations which 'are not always personally, culturally or contextually appropriate'.

In overcoming this difficulty many authors advocate that theories of lesser scope and abstraction are considered (McFarlane, 1976; Clarke, 1986; Draper, 1990; Moore, 1990; Ingram, 1991; Reid & Bond, 1991). Such theories have been termed 'mid-range' and address a more limited number of variables in particular situations (scope), whilst being empirically grounded and focusing on practical problems (abstraction) (Rogers & Shoemaker, 1971; Walker & Avant, 1983; Fawcett, 1984; Lowenberg, 1984). According to Clarke (1986), mid-range theories should appeal to practitioners as being more directly accessible conceptually and linguistically. Reed & Robinson (1991) contend that, given the diversity of nursing practice, the search for grand theory is inappropriate and nursing would be better served by developing mid-range theories that are 'more precisely stated, more easily treated and produce more specific indications for practice'." pp. 59-60.

Smith, J.P. (1994) Advanced Nursing Series - Models, Theories and Concepts. Oxford: Blackwell Scientific Publications.

While the structure of Hodges' model is global - 'grand' in scope, the model, as a template is blank and open to whatever conceptual content follows in the practice situation, or context. 'Precision' can be assured using Hodges' model as it can facilitate person-centred care, integrated care, reflection, critical thinking and conceptual development. 

Delivery of high-quality health care is not a given. 

Safe, effective and equitable care is variously dependent upon staffing, the skills and attitudes of individual nurses, staff numbers, skill-mix, team effectiveness and resource allocation. Hodges' model can also assist users to recognise and call-out unmet needs, deficits in the quality of care, and risks to the safety of patients, the public, staff and the profession.

At risk of sounding grand if not grandiose ...

Change will and must follow - in respect of models and theories, not just of and for nursing but health and care at scale.

Update on draft papers iii

There was news today about the draft paper on:

"First Episode of Psychoses, Early Intervention, Cardiovascular Nursing, Research Methods and Hodges' model."

It has been accepted and I can submit formally. 👍

This project - yes, a further distraction (that has borne fruit) started in March resulting in 4,800 words, an illustration of the model and 4 figures (2x2 tables). That I think, with the editors, guide the reader in applying Hodges' model, or at least the scope of its application, which is situated and person-centred.

I approached a journal regards the draft "Society, Technology and COVID19 in Hodges' model". Having reduced the original 12000 words to 7700, the paper is of interest, but is (as expected) too long. There is the possibility of reducing the word count to 5000, or splitting the essay.

This invites revisiting the original and teasing out the informational themes: fake news, mis- dis- malinformation and agnotology (in part 2?). Then I would (to a degree), finally be returning to the concept of 'information':

Jones, P. (1996) Humans, Information, and Science, Journal of Advanced Nursing, 24(3),591-598.

- which keeps 'calling' (with complexity, emergence...).

I will consider the options, but submit the above: an instance of much appreciated encouragement and support by the editors. Writing this has proved an enjoyable challenge.

As ever, if you have any sources to add to the bibliography, wonder about using Hodges' model I would be pleased to hear from you: h2cmng at yahoo.co.uk

Pioneering safe staffing whistleblower nurse dies aged 91: c/o RCNi

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

Graham Pink at his home in Manchester in January 2008 Picture: Neil O'Connor courage : compassion : values : commitment : leadership

"A nurse who was among the first in the UK to blow the whistle on safe staffing issues has died aged 91. Graham Pink first raised concerns about poor staffing and the dangers to patients when he worked at Stepping Hill Hospital in Greater Manchester in 1990. His four-year campaign to highlight inadequate staffing levels made a lasting impression on the nursing profession. Mr Pink died on 6 March in Barnsley, South Yorkshire. Nurses caring for him remembered his safe staffing campaign Speaking to Nursing Standard about his final months, his niece and carer Sarah Pink said: ‘Barnsley Hospital gave him a lot of care and attention and treated him with a huge amount of respect. There were nurses caring for him who said they knew him from what he did and how he stood up for the NHS back then. One sister said it was an honour to meet him and take care of him.’"

HRH The Duke of Edinburgh RIP

https://www.rcn.org.uk/employment-and-pay/safe-staffing

My source: RCNi via twitter: 

https://twitter.com/rogerkline/status/1380398894740348929?s=20

14-20 March - Patient Safety Awareness Week

Next week 14-20 March is Patient Safety Awareness Week. 

Further information here:

http://www.ihi.org/Engage/Initiatives/Patient-Safety-Awareness-Week/Pages/default.aspx

​​​​​​​​​​​​About the Initiative

Patient Safety Awareness Week is an annual recognition event intended to encourage everyone to learn more about health care safety. During this week, IHI seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce.

Patient Safety Awareness Week serves as a dedicated time and platform for growing awareness about patient safety and recognizing the work already being done...

--

 

[See link above for events - webinars.. PJ]

My source:

 

Neil Pakenham-Walsh, HIFA Coordinator, neil AT hifa.org www.hifa.org

HIFA: Healthcare Information For All: www.hifa.org

Moral injury: Individual - Collective: 'Global'

INDIVIDUAL

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

GLOBAL POPULATION

	A year ago, #COVID19 emerged & sparked a pandemic. Life-saving vaccines have been developed. What happens next is up to us. If we don't #ACTogether, the 🌍 is on the brink of a catastrophic moral failure & the price will be paid with lives & livelihoods in the poorest countries. pic.twitter.com/QkriFnNfEC — Tedros Adhanom Ghebreyesus (@DrTedros) January 18, 2021

Sources:

Several news sources.

Patient Safety Learning

Textbook of Patient Safety and Clinical Risk Management

Textbook of Patient Safety
and Clinical Risk Management

About this (open access) book

Implementing safety practices in healthcare saves lives and improves the quality of care: it is therefore vital to apply good clinical practices, such as the WHO surgical checklist, to adopt the most appropriate measures for the prevention of assistance-related risks, and to identify the potential ones using tools such as reporting & learning systems.

The culture of safety in the care environment and of human factors influencing it should be developed from the beginning of medical studies and in the first years of professional practice, in order to have the maximum impact on clinicians' and nurses' behavior. Medical errors tend to vary with the level of proficiency and experience, and this must be taken into account in adverse events prevention. Human factors assume a decisive importance in resilient organizations, and an understanding of risk control and containment is fundamental for all medical and surgical specialties. 

This open access book offers recommendations and examples of how to improve patient safety by changing practices, introducing organizational and technological innovations, and creating effective, patient-centered, timely, efficient, and equitable care systems, in order to spread the quality and patient safety culture among the new generation of healthcare professionals, and is intended for residents and young professionals in different clinical specialties.

https://link.springer.com/book/10.1007%2F978-3-030-59403-9#about 

My source: HIFA - https://www.hifa.org/

"The complexity of many safety-critical systems makes an a priori analysis of possible system failures and human errors impossible and unreliable. Despite this, it is considered useful to apply this type of healthcare technique to promote reflection among frontline operators before introducing technical or organizational innovation. For example, before introducing a new procedure, it is useful to reflect on the possible, critical aspects of the different phases of the procedure, or, in the case of technological innovation, back-up solutions can be prepared to deal with any malfunctions of the instrument." p.139.

"The role of non-technical skills for patient safety has progressively become more evident through the years and, on this topic, one of the most striking moments of reflection for the healthcare community was Martin Bromiley’s report [10] on the death of his wife in 2005. Fixation errors, absence of  planification, teamwork breakdown, poor communication, unclear leadership, lack of situational awareness, and other non-technical aspects of performance in anesthesiology and critical care medicine can negatively impact patient outcome." p.161.

"In other words, HFE [Human Factors and Eronomics] takes a systems approach that acknowledges the importance of context, emergence and holism in elucidating interactions between various system elements and developing this understanding requires being embedded in the system." p.151.

 W2tQ: safety

 

When what is political turns Yellow ...

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group - population

 

My source:

https://twitter.com/MHRAgovuk/status/1306201325903007745?s=20

The humanistic and mechanistic in patient transport & safety

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group - population

Person - Identity 'Suspended personhood' ? Dissociation -> Alienation ? MENTAL - physical health Clinical assessment Mental Illness Mental Health Crisis Orientation - Mental capacity Anxiety - Distress - Stress 'Lived experience' Risk to Self / Self neglect Can person's needs be met? Trauma Individual sense-making "If I am in a cage ..." SUBJECTIVE - objective QUALITY - quantity Aesthetic (psychological) impact of conveyance

PHYSICAL - mental health Open - Closed Wards/Units Locked - Secure Clinical assessment Risk to Self / Self neglect Physical MECHANICAL restraint: Handcuffs Vehicle: Cage vans - confined space Logistics: Patient transport 'Transfer' local <---><-> remote Location of Specialist Units Number of places Data gathering Records OBJECTIVE - subjective QUANTITY - quality

Risk to Others Ability to cooperate Families - contact / visiting Shared lived experience: Treatment, Care Vs. Punishment Patient-Public Involvement Discourse Collective sense-making Perpetuation of stigma Blunted / Polarised dialogue:  Anti- Critical Psychiatry Barriers to dialogue: 'Service-users' - Services

Police & Policing Law Mental Health Act Mental Capacity Act Liberty Protection Safeguards Duty of Care Accountability - Liability Staff involved in transfers Policy Policy Instruments Data - Reporting: Commissioned Research? Employee safety Mental Health Services Commissioning: Private Sector - Public Sector Transport Services Standards Psychiatric Intensive Care Unit

I'm sure the vast majority of transport service providers - public and private, are of a high-standard, seek to assure safety of all involved and professional, but exceptions must be addressed.

See also:

Carli Brosseau and Alex Lang

Read more here: https://www.newsobserver.com/news/local/article230255979.html#storylink=cpy

‘How many have to die?’ SC mental health patients endure nightmare transport conditions.

https://www.newsobserver.com/news/local/article230255979.html

If I come across further information (esp. UK centred) I will add here.

h2cmng AT yahoo.co.uk

Read more here: https://www.newsobserver.com/news/local/article230255979.html#storylink=cpy

My source:

Cage vans are used routinely in the UK for patient transport between hospitals. There is currently no record of how frequently used. There is no requirement to demonstrate that this degree of imprisonment is proportionate, or that less restrictive transport is impossible https://t.co/jvVL2atSVe

— Alex Thomson (@AlexBThomson) July 25, 2020

Person-Centredness and Safety: 25st / 350lb / 159kg

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group - population

	https://www.bariquins.com/ ... doors and doorways, entrances, exits, passages, chairs, stretchers, hoists ... moving - handling ...

My source:
Twitter:
https://twitter.com/Bariquins

What's in a Name?

  Or, The First Rule of First Aid* ... #SafeStaffing

Health care is often described as complex ...

there are tools to help simplify, conjoin 

and help care navigation and learning ...

Despite this and even if people are listening

politics, politicians and policy makers seem determined to turn health care into a maze ...

INDIVIDUAL

|

INTER-PERSONAL : SCIENCES

HUMANISTIC -------------------------------------------------- MECHANISTIC

SOCIOLOGY : POLITICAL

|

GROUP

*Protect yourself first.	"WAITING ROOM" "WAIT HERE"

RCN Safe Staffing Campaign:
https://www.rcn.org.uk/employment-and-pay/safe-staffing

patient safety learning hub:
https://www.pslhub.org/

'Named Nurse' 25 years ago.
Mitchell G, Strain J. The role of the named nurse in long-term settings. Nurs Older People. 2015 Apr;27(3):26-9. doi: 10.7748/nop.27.3.26.e679. Review. PubMed PMID: 25809049.

My source (and image):
https://twitter.com/helenh49/status/1210956380636663813

Future - History: Information Systems or Care Records

Brian Warboys Professor of Software Engineering at Manchester University has stated that clinical staff lack the skills to make working information systems should leave it to IT professionals. A consultant physician and cardiologist at Bloomsbury and Islington agreed, the HSJ quote as saying:

"The fault lies not with the IT experts but with ourselves as clinicians. If we do not tell them what we want, how can they come up with the answers? ... There is a case for evaluating every IT solution available now and scrapping some of them". p.8.

Health Service Journal, 101:5259, 4 July, 1991.

'Coroners have warned the NHS on dozens of occasions that its record-keeping is so poor that patient's lives are at risk, an investigation by The Times has found. ...

Coroners have issued 62 warnings since 2013 in which they identified failings in record-keeping that could lead to the deaths of other patients.' ...

 'Simon Eccles, of NHSX, which is responsible for improving digitalisation, said that all of England should be covered by digital records by 2024 so staff could access the information needed to provide patients with the best possible care.'

Greenwood, G. Lost notes and illegible records 'risking lives of NHS patients'. The Times, October 2. 2019. p.16.

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

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

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?

#HSJpatientsafety Fallacies of work as imagined. More info on Steve’s great blog https://t.co/i5TCs6CLvJ @StevenShorrock

— Iain Moppett (@IainMoppett) July 3, 2019

Q. "How can Technology Save the NHS?"

A. It can't - on its own.

Image: Sept 18 2018 The Times Tech Summit Supplement
https://the-dots.com/projects/google-cloud-tech-summit-cover-249662

"On 20th October 2008 50 members of the UK Faculty of Health Informatics attended a master class entitled: "10% Technology 90% Business change - Maximising the added value of new technology for the NHS."




"At the event itself, and afterwards using a post-event wiki, members tried to address the question of: What should be done to make, what is often called a "sociotechnical" or "user-centred" approach to the delivery of technology projects the norm in Health and Social Care?"



Ref.UK Faculty of Health Informatics.(2008) 10% technology, 90% business change; maximising the added value of new technologies for the NHS. Discussion Paper, NHS, London.

A. Anyway, if by 'save' you really mean 'save' then pay and support the necessary staff first then consider the 'technology': socio-technically.

Nursing's Golden Ratio: Safe-Staffing:Law

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group - POPULATION

Care Philosophy: Task orientation Vs Person-centred (Reality: Hybrid that assures person-centredness?) Individual Patient's, Friend's and Family impression Individual Patient's, Friend's and Family experience (AND memory) Confidence in Care (Confidence as a Learning Environment)  Individual Nurse's Values Individual Patient Outcomes PURPOSES	Numbers - count "40,000 missing Nursing" [RCN] Ratios: x :: y Staffing Research (Falls, Quality...) Operational Research; Measures Dependency; Chronicity; Nursing hours / day; Skill-mix; Care undone Productive Nursing Care Demographics: Local, National, Int. TIME: tasks, events, priorities, shifts The E's: Efficiency, Effectiveness, Equity, Equality  PROCESS
Qualitative Duty of Care Public awareness / sensibilities History of Research into Staffing (Time and Motion studies) Direct Nursing Care High Quality Nursing Care = The Golden Ratio PRACTICE	Quantitative Recruitment, Retention, Attrition Workforce Planning Professional Accountability Commensurate: Policy - Law NMC Code of Conduct Contract of Employment Employment T&C Emigration Policy, Overseas Workers Professional Bodies inc RCN, Unions ... Nurse Administration Support Information System - Synergy?  POLICY

My prompt with thanks: https://twitter.com/DannGooding/status/1110929934262898689


Additional sources [ c/o @DannGooding ]

A critical moment: NHS staffing trends, retention and attrition
Health Foundation, ISBN: 978-1-911615-25-5

RCN

American Nurses Association, Nurse Staffing Literature Review

Musings on Integrated Care: A Visible and Invisible Matter

If measures for clinical outcomes, health literacy, patient satisfaction, benefits and many more present a challenge then a measure for integrated care falls into the category of a very steep peak.

It's a nebulous concept, we know what we mean, we recognize the principles and we even allow for variation in what integration and integrated care means for different people.

The January 2012 integrated care report by The King's Fund and Nuffield Trust (previous post) had me thinking about some of the ingredients that might contribute to measures of integrated care and our efforts to record it. What instruments and formats do we need - what mix of microscope (individual), telescope (population), strobe (snapshot), time lapse (series), objective - subjective? Some elements  then (in no particular order):

Breadth of the 'episode' (primary-secondary-tertiary-palliative)
Breadth across an individual's lifespan - as needs change and assuming person-centredness
The number of systems
  information - e-records
  commissioners
  datasets: total, number of gatherers, submissions of data, local, regional, national, global
Demographics: population profiles, housing provision, local need
The number of people - individuals involved
The number of 'responsible' organisations
 Primary organisational efficiency - Lean Standing?
The number of teams
The number of policies (policy touches)
 The number of interviews, assessments (paper, electronic, formal), care plans, reviews
Opportunities for communications
  potential
  actual
  media forms
  delivery forms (inc. technologies)
Number of handovers - communication
  weighted according to type?
Patient experience - measure
 (that is holistic across physical, mental health, social care?)
 staff attitude
 therapeutic relationship engagement (quality)
 therapeutic modalities (quantity)
 educational content, materials provided / information gains
 number of patient (carer) choice points (potential - exercised)
Incidents of positive risk taking
Increase in health literacy as this is a policy priority
 - a priority linked to integration of disease response and  prevention
Co-ordination effectiveness
Self-care - autonomy, decision making
Patient (carer) as budget holder
Patient as record holder and direct data source (telecare - data entrant)
Carer involvement
Health : Social care (main dependency, ratio, index)
The number of disparate care philosophies encountered
Diagnoses
Diagnostic investigations complex (location, time)
Declarative success: agreed plan - success?
The geographic encounter footprint: distance, travel, transport, environment
Duration of engagement
Follow-up - care continuity care
Care Disintegration - safety
 care interrupts^# (falls, errors)
 relapse, readmission
 dependency (deferred discharge)
Influence of public engagement - involvement in local health services^*

While many of the above might qualify as candidates for a measure of integrated care, you have to wonder whether in order to measure integration you must measure everything else. It appears here at least that integration and complexity are closely related. Several of the items above might individually represent - and no doubt do - indices of various kinds that also beg definition (e.g., co-ordination, success, philosophies, episode ...).

Although I've referred to 'numbers' you could no doubt refine the list by consulting the literature and considering the quantitative : qualitative mix.

Perhaps the key indicator of integrated care isolates the primary concepts for the person concerned and then fuses those within the INTERPERSONAL and POLITICAL care domains (policy touches would be one example)?

^*How does a measure of integration incorporate those socially excluded?
^#For want of a better word. 

Frontline or tightrope?

As the various media outlets and commentators discuss health care, nursing, medicine and social care they often refer to the frontline -

Where exactly is the frontline these days (and nights)?

Who is on the frontline?

Is the frontline always visible?

Is there a 2nd, 3rd or 4th line?

Are there any gaps in the frontline?

Is it twisted at any point?

When health care economics is squeezed
how does this affect the frontline?

Does the frontline have an optimal tension?

If the frontline is Lean, in lean times
does it have a harmonic?

How has the frontline changed over
the past 20 years?

How is our frontline forecasting?

Is there space on that (front-) line for
partners, information technology,holistic
bandwidth, values, policy, safety ..., ....?

All doodles welcome.

Editorial JRN. Coalition in leadership: Politics - the big picture and the big game

In the Journal of Research in Nursing, Veronica Bishop's editorial -

Coalition in leadership.
Politics - the big picture and the big game

- explores the state of the body politic in nursing. Bishop's focus is research, but the implications extend beyond the UK, to nursing globally. The body is indeed immersed in politics, but it seems the feet are dry and there is no one at home.


Considering that The Politics of Nursing by Jane Salvage was published c. 1991 political maturity is long overdue?

While the sexual politics of nursing have been campaigned for in the nursing media and vigilance is needed, it seems that a political birth for nursing needs to be induced. There is a political mentality there, there has to be. The future is too challenging, too fraught, too close to be mollified by appeals of "Anything for an easy life (and death)!."

Bishop begins with a quote:

The very essence of leadership is that you have to have a vision. It’s got to be a vision you articulate clearly and forcefully on every occasion. You can’t blow an uncertain trumpet.
Theodore Hesburgh (1917–(2015))

If you are familiar with Hodges' model then you know what is coming. ... In quantitative (and qualitative) terms 25% of our deliberations using Hodges' model can be POLITICAL. This is not just the political dimensions of the patient, carer and the health and social care enterprise. The model includes the practitioner, but back to Bishop:

Having ‘power’ is a concept that sits uncomfortably with many nurses – it does not fit with the ideal of caring and many clinical nurses are quite open in their lack of regard for those in management, seeing them as power-seekers rather than power-movers. Clearly nurse leaders have in many cases failed to take their clinical colleagues with them in the drive to put nursing where it belongs, at the decision-making point that drives the agenda for health services, a point borne out by Stanley (2009).

How ironic that 'comfort' itself has been the subject of concept analysis and theorising in the nursing literature. If student nurses are exposed to the POLITICAL from the outset of their careers, then surely at the very least they will be more comfortable dealing with the guises and disguises of power?

Bishop refers to leadership and ownership and the two are frequently conjoined. The question of politics in nursing - in thought, practice, management and policy (research!) - makes me wonder ownership of what?

If the political domain is so frequently a vacant lot as far as nurses are concerned, then perhaps when we do put in an appearance we are not taken seriously. It really is a case of: what are you doing here?! As Bishop points out through -

Nurses are scientific. When they want to get to the core of a problem they always try to drill down. Yet politics are about the big picture. Nurses are agriculturalists in that they grow and nurture things but politicians are hunters – they’re always after the big game. It’s these kinds of differences nurses need to start to understand. (Cumberlege, 2007).

Nurses are there in the POLITICAL domain: they are constantly trying to complete the big picture.

... we were considering the best way for her [Baroness Cumberlege] to approach an interview the following day, and eventually, after we had viewed the uppermost issue of the day from every angle she said ‘Oh, nursing is so big!’. How right she was – there is hardly any aspect of life that it does not overlap or impinge on, so considering the big picture is a mammoth task! And again, she was right, we need leaders who have clarity and energy, and can cut through the detail and focus on the professional entity.

Yes, the big 'P'-icture is a mammoth task, hence the need to uncover, compose and frame it early. POLITICS is not just a matter of whistle blowing, industrial relations, policy, the system, us-and-them, banner headlines. ...

Politics is much more and crucial to research as Bishop attests. So, if our students do not reflect upon and articulate the politics of health: ill-health, well-being, equality and inequality, wealth and poverty ... then that professional entity will be a political ghost. A ghost playing a little game in an alien and alienating domain.

Veronica Bishop (2010) Coalition in leadership. Politics - the big picture and the big game, Journal of Research in Nursing; 15; 291.
DOI: 10.1177/1744987110374692