Holistic care: What is 'holistic bandwidth'?

The old website with its pages is static. In thinking about how to mix the old and create new dynamic content for a Drupal based site, I came across a possible way to define and explore our notions of holistic care. Here are some very initial musings....

First to focus on quantity. In completing an assessment whichever care domain I start in (let's say the intrapersonal domain) then as that domain is populated can it be argued that within the other domains the same number of placeholders for our assessment data are created? If my patient has eight problems (and two strengths) then according to one definition of holistic bandwidth the remaining domains should have the same number of problems (and strengths). Balance in all things - including holistic care?

One thing that the ADLs teach us is that (holistic) care as represented in Hodges' model is asymmetrical.

This does not mean that the ideal of holistic care is lost.

It might mean that strident efforts to assure holistic bandwidth can interfere with our attaining person-centred, integrated and multidisciplinary care.

It is essential that we recognise holistic care as an ideal, as a constraint and the primacy of functional considerations in:

• assessment;
• planning;
• care interventions;
• evaluation;
• and governance.

It comes as no surprise then that there are several versions of holistic bandwidth:

1. If we want to be inclusive then version #1 is epistemological. This anticipates the total number of semantically associated concepts that can potentially arise in a given care episode. This is what might be termed the 'semantic web of care'.
2. The sum total of concepts across all the care domains (inc. spiritual) that are actually activated in the course of a care episode.
3. The concepts that are deemed relevant by the patient, carer, family and guardians.... These add holistic value to and may well (must!) overlap with the care concepts recorded by the clinical team and reflected in the health record(s).
4. The degree of expressiveness of the care recording system - its capacity to represent holistic care and capture (measure) holistic bandwidth pre- or post- care episode completion.
5. The (idealised and learner generated) collections of care concepts identified and enacted within education.
6. The idealised and actual collections of holistic arrays applied and recorded by the combined clinical and social care disciplines* involved (there are two sets in practise and theory). As per #3 these (should) overlap with the patient and carer's....
7. The final combined lexis of written, electronic and other record(ed) media that constitutes the final:
• personal health record;
• summary health record;
• historical health record;
• clinical record;
• ....
• all the above combined;
• an individual and group's (family) health career!
8. In addition there are the anonymised and aggregated data items that form part of clinical / management reports, local, central government statistics and returns that inform national health and social care policy and global health intelligence at the WHO.
9. Throughout 1-8 holistic bandwidth must also incorporate education, engagement and informatics.

It is reasonable to speak of personal and impersonal forms of holistic bandwidth.

Students - if this is helpful or confusing please let me know h2cmuk @ yahoo.co.uk

Holistic care No. 2: Definitions - pushing the envelope checking the corners?

Last month I posted about holistic care; where was I up to? Yes, of course definitions...

I came across this article that includes reference to Jan Smuts (1926) who is generally attributed with coining the term holism. The article also highlights that holism is often associated with alternative medicine. I'd like to suggest here that holism extends far beyond any specific school of medicine or new ageist theme. A conclusion reached from contemplating the state of the World and using Hodges' model. So let's consider holism as a feature, characteristic or principle of care theory, practice and policy. What follows may well apply generally.

To begin, if health and social care (plus pastoral) is to be person-centred and situated then agency (who) must be a central factor in defining holism - holistic care. Then I would add the concept of information followed closely by knowledge. Stepping back slightly 'holistic' in h2cm denotes openness, inclusiveness and comprehensiveness.

AGENCY: In Hodges' model I think there are four aspects to agency:

1. The person who is the 'patient';
2. The health / social care agent;
3. Others associated with the patient (family/friends as carers);
4. The population at large (local, national through global).

The definition of the health care agent can be described as idealised or actualised; implicit or explicit; indirect or direct(?)

Please pardon the verbiage here both that last sentence and the volume. I'm still trying to figure this out. If you hadn't noticed I'm scribbling all this on an envelope. Any assistance or suggestions gratefully received.

A definition needs to account for the way it [holistic care] is used in day-to-day language, across various settings and contexts. To explain a bit more: imagine there is a community service with a multidisciplinary team that is 'holistic' in that it includes all professional (qualified and unqualified) disciplines, and voluntary practitioners of care. In combination this holistic service bring with them a range of knowledge and skills that is comprehensive. There are distinct pools of specialisation, with the inevitable overlap of some skills - otherwise how could people co-work? So on paper this team could - idealistically - be said to be 'holistic'.

If, however, all of these agencies were to be involved in a single case, then another definition of 'holistic care' emerges. This highlights the importance of context on working definitions derived from the service (agent) side, in contrast to definitions from the patient (subject) perspective and policy (Government). If you need some indication for the level at which Hodges' model operates look no further. At this level the patient and informal (family) carers are also agents, supporting the notion of self care.

It could well be that the whole team are legitimately required to respond to a referral, but if not this would constitute a huge waste of resources. The actualised sense of holistic care is expressed in policy - interventions must be commensurate with need. We cannot divorce health care from governance and economics. In fact there may be a case of abuse to answer for. You really can have too much of a good thing.

Point #4 above may seem to stretch the concept of agency too far. Problems first launched in the 19th century are coming home to roost. There is (currently) nowhere to run or fly. The inclusion of local through global sense of agency is a MUST. Patient care is de rigueur, self care is a major challenge*, both are insufficient in terms of achieving holistic care:

Staff: "Always observe discretely and check the welfare and safety of the quiet, withdrawn patients in your care."

Student: "Who's that sat in the corner?"

Staff: "Where? You mean the lady sat in the other corner don't you?"

Student: "Hold on .. why - she's in all four corners, in fact she's everywhere..."

Staff: "Oh, yes that's right her name's Mrs Green and actually she's not so quiet these days. It's all very sad. We're trying to include her in things."

Student: "What's the problem?"

Staff: "Some very complicated and damaging relationship problems, gross personal assaults of the worst kind that we can't discuss here, but the lawyers are talking about crimes against humanity.... All her children are threatened. Goodness is that the time! Is it time for your break? Perhaps you could go try and speak to her. Better still maybe just listen..."

INFORMATION: If agency is primarily centred on the left side of h2cm namely the humanistic axis with the INTERPERSONAL & SOCIOLOGAL domains - then this needs to be counterbalanced if the model is to mean something. ICT (information and communication technology) IS an essential factor.

For our purposes though we need to fracture this union and separate out information, communication and technology (Intensely Confusing Terminology?).

If we untie the digital knot, then we can better reflect upon the sociotechnical dimensions of holistic care.

KNOWLEDGE: This brings us to the next definition that can be built on conceptual and prepositional foundations. A definition of holistic care relating to knowledge can (surprise-surprise) also utilise Hodges' model.

I've to pull-the-plug somewhere - sorry info and know are very brief. Thanks for stopping by awhile, safe travels until we meet again at this crossroads.

I hope you'll be back and that these reflections are helpful?

More to follow: Holistic care No. 3: Location

holism: Smuts, J.C. (1926) Holism and evolution. New York: Macmillan.

*The real challenge is avoiding the need for self-care!

HealthTap: Invited to add their widget... I asked a question...

No doubt it was a bulk email, but I received an invitation from HealthTap to add their widget here on W2tQ. The widget provides the means to access their service, that of putting questions to medical experts.

I have minimized the side bar content, stripping out buttons and other media paraphernalia and yet suitably intrigued I asked a question - ;-)

Q. Is there a conceptual framework that can help

 assure holistic (physical - mental, social) and integrated care 

that is also person-centered? 

Fourteen hours later an answer duly arrived by email:

Holistic Medicine
I believe that Holistic Medicine, when properly practiced, assures all of that. For the principles delineated by the American Holistic Medical Association see ...

Also see ...


I greatly appreciate Dr. Randy S. Baker's response and the above links. This is helpful in several respects despite not exactly being the answer I was hoping for.

The answer is itself holistic in a sense in wrapping the question up in an organisational wrapper. That's a safe response, with medicine in there for wholistic measure. Who ever said medicine is reductionist! Judging from his profile holistic medicine is Dr Baker's forte.

Also interesting in the answer is the way the hook in the question was deemed to be the reference to 'holistic' and not the conceptual framework element.

Another point in Dr Baker's reply that reflects on Hodges' model and the health news media in England (UK) next week* is the bit about when properly practiced.

The adoption of Hodges' model is no guarantee of 

person-centered, 

integrated, 

holistic care.

Although the term conceptual framework (Hodge's model !) is not given in the answer: assure is.

What ever conceptual framework (care model, care philosophy...) is adopted to deliver health care, they must contribute towards the assurance of high quality care - that which ultimately positively engages the patient, carer, family and communities.

My question still remains and is usefully extended, passed to the above organisations.

So does the AHMA and the American Board of Integrative Holistic Medicine have a conceptual framework that helps support their holistic objectives and assurance of care? I will contact them to see if I can obtain a further response.

Thanks again to Dr Baker and HealthTap.

* The Francis Inquiry Report is anticipated on Wednesday.

H2CM: Some Reflections on Purposes

Of the purposes associated with h2cm:

1. To produce a curriculum development tool.
2. Help ensure holistic assessment and evaluation.
3. To support reflective practice.
4. To reduce the theory-practice gap.

(Source: Brian Hodges)

- the primary purpose must be to facilitate and support holistic practice. The reasoning for this runs (it is hoped) as follows:

Although reflection is often conducted with a particular task - frequently a question - and hence a set of associated experiences in mind; the individual should be encouraged to think universally. If in general reflection is constrained then perhaps the activity is no longer reflection?

If the curriculum developers intend to produce holistic practitioners* then once again holistic considerations should preempt and influence curriculum development.

Theory and practice are surely as 'holistic' as holistic is? This purpose though seeks to assist in closing the theory-practice gap and the existence of this gap suggests that there is something else – even if only space. This space means we must once again defer to holistic.

Or am I getting confused...? What do you think? h2cmng at yahoo.co.uk

*holistic in terms of the range of thought (holistic bandwidth) - not holistic new-age therapies.

TO: EU -omics research community; if you are seeking a holistic approach for personalised medicine...

The relevance of Hodges' model as a resource in 21st century health care and research can be found within personalised medicine.

This is in addition to the need to assure holistic bandwidth within existing health care delivery, when it is person centered care that is the concern. Personalised medicine brings with it further challenges as it emphasizes the scientific, the inevitable reductionist work can potentially increase the distance between the humanistic and the mechanistic. The working document from the European Commission -

Brussels, 25.10.2013 SWD(2013) 436 final COMMISSION STAFF WORKING DOCUMENT. Use of '-omics' technologies in the development of personalised medicine
http://ec.europa.eu/health/files/latest_news/2013-10_personalised_medicine_en.pdf

on page 7 we read:

The figure is instructive as it shows that a holistic approach is needed to fully appreciate the challenges and opportunities presented by personalised medicine. 

'Holistic' is a much maligned word, with its fuzzy, new age connotations. Especially when the word count = '1'. Another related document also picks up the holistic call:

IMI2 will deliver tools, methods and prevention and treatment options (directly or indirectly) that will progress the vision of personalised medicine and prevention. Through providing the framework required to support collaboration between scientists, regulators, HTAs, patients and healthcare providers, IMI2 will ensure that research is translated into implementable solutions to current healthcare challenges. Solutions that are not purely focussed on the development of new medicines, but that provide a holistic personalised healthcare package as well as maintain people healthy and productive through out their lifetime. Reclassification of diseases based on their root cause and not symptoms will help addressing unmet needs even in areas where a range of options exist but patients do not respond, because their symptoms are misleading therapy choices.
[ IMI - Innovative Medicines Initiative ]

Outline Strategic Research Agenda for a biomedical research public private partnership under Horizon 2020: (draft) The right prevention and treatment for the right patient at the right time. 08 July 2013. (pdf link removed file not readable)

On page 10:

A sustainable healthcare system is a holistic one in which the patients are responsible for their wellness and quality of life; physicians, therapists, nutritionists, community carers, and all other actors in the value chain are motivated to this goal; delivery of care takes into account patient beliefs, values and both rational and irrational behaviors; the care is affordable to both public and private payers and promotes health; sustainable businesses can thrive; and the education, prevention and management of chronic conditions are aligned to achieve this goal.

The focus of these documents is -omics and the development of new medicines. By its very nature this research, data and knowledge lies deep within many sciences: new sciences no less. This recognition of the need for holistic approaches and perspectives is still very encouraging. As the first document on personalised medicine notes, future treatments must be from "bench to bedside". We can equate this as "mechanistic to humanistic", but only as long as the patient in that bed is a person and not just viewed as a diagnosis with an associated -omic profile.

Have a look also at the figure on page 7, the medical innovation cycle. As discussed previously on W2tQ patient safety needs situated awareness and holistic perspectives.

My original (and seemingly incomplete) source:
http://www.researchresearch.com/index.php?option=com_news&template=rr_2col&view=article&articleId=1339313 [no longer available]

Sour grapes and 'holistic' academic publishing

Having been a student on several occasions, an independent scholar and online for the past decade (I was a late arrival) something is really getting on my pips.

When I see an Editorial entitled -

Theoretical Frameworks 

and Concept Development

in an established publication -

Journal of Holistic Nursing

That states - 

There is a commitment within holistic nursing to explore and refine terminology and frameworks that will enhance the care of patients and provide understanding about the healing process. To accomplish this directive, manuscripts will be published that provide an in-depth analysis of existing, alternatives, or extensions of concepts, frameworks, or theories associated with holism and holistic health and nursing. Holistic nursing involves a complex view of the individual, family, and environment that is constantly being challenged by new and emerging paradigms and information that furthers the ability to understand humans as multidimensional and pandimensional beings.

I do wish someone else would recognize the
holistic value inherent in Hodges' model.

That value is not there by default it has to be found, learned and earned, but there are few frameworks that can simultaneously encompass holistic nursing, healing, touch, global health, informatics disciplines, the green agenda and human ecology. ....

So come on just a whisper - who Dares...?

 

Ref:

Diane Wind Wardell, Editorial, Theoretical Frameworks and Concept Development, Journal of Holistic Nursing, American Holistic Nurses Association, Volume 27, Number 3, September 2009 158.

Additional links:

How many interfaces are there? 
http://hodges-model.blogspot.com/2007/04/hodges-model-how-many-interfaces-are.html

Hodges model: What is it? [2] It’s an interface...

http://hodges-model.blogspot.com/2007/01/hodges-model-what-is-it-2-its-interface.html

Lonely model seeks ...
http://hodges-model.blogspot.com/2007/12/lonely-model-seeks.html

Nurses - Ask 5 complimentary questions

I received an email from RCNi subject heading - 'Q. What questions are nurses asking?'

An invitation to sign-up and ask five free questions: https://rcni.com/ask 

Question 1

Is there a model of care, or nursing that encompasses the sciences, mental health, sociology and political domains of care?

Several models of care and nursing frameworks integrate diverse domains beyond purely biological aspects, encompassing scientific, mental health, sociological, and even political dimensions. These models emphasise a holistic approach to patient well-being, recognising the complex interplay of various factors in health outcomes.

• Social Model of Health: This model focuses on salutogenesis, examining what contributes to health rather than just illness, by considering broad social, economic, environmental, and cultural influences on an individual's well-being .
• Person-Centred Nursing Framework: This framework extends beyond individual biological health to include the person's intricate cultural context, family, spirituality, and life experiences, defining health as encompassing intellectual, social, and spiritual dimensions .
• Biopsychosocial Model of Care: This approach integrates biological, psychological, and social factors to address a patient's holistic needs, moving beyond the biomedical model's sole focus on physical illness .
• Dual Registration Degrees: Educational programmes for nurses and social workers combine life sciences with social work principles, law, and policy, preparing professionals to understand factors influencing health, social justice, structural inequalities, and anti-discriminatory practises .
• Multidisciplinary Team (MDT) Care Model: While not a nursing model itself, the MDT approach enhances patient care by integrating expertise from various professionals, including specialist doctors, nurses, psychology counsellors, dietitians, and pharmacists, to deliver individualised treatment plans and coordinate care .

Modern healthcare increasingly recognises the necessity of comprehensive care models that extend beyond traditional medical approaches. These integrated frameworks, including the social model of health, person-centred nursing, and the biopsychosocial model, provide a foundation for understanding and addressing the multifaceted nature of health, incorporating scientific, mental health, sociological, and policy-related aspects to improve patient outcomes. [Five references provided - hence poor formatting in transfer.]

Question 2

What model of care has the conceptual scope to critique parity of esteem in mental health nursing?

Critiquing the concept of parity of esteem in mental health nursing requires models that move beyond a purely biomedical focus to embrace holistic, person-centred, and culturally sensitive approaches. These models emphasise equality, social justice, and comprehensive care, addressing the historical imbalance between physical and mental health provision.

• Biopsychosocial Model: This model offers a conceptual framework to critique parity of esteem by considering biological, psychological, and social factors in a patient's health, aiming for holistic needs rather than just biological ones . It contrasts with the biomedical model, which has historically led to paternalistic decision-making in healthcare .
• Culturally Sensitive and Competent Care: Essential for critiquing parity of esteem, culturally sensitive care requires nurses to appreciate diverse cultures and adopt personalised, flexible approaches to mental health support . Culturally competent care, underpinned by equality and diversity principles, involves behaviours and attitudes that value patients' diverse backgrounds, improving satisfaction and outcomes .
• Person Centred Care: This approach is crucial for addressing the historical paternalism in healthcare, ensuring patients participate in decisions about their care and re viewed as individuals with unique experiences rather than just labels or symptoms . Recent mental health reforms, such as the Mental Health Bill 2025, aim to embed person-centred and equitable care further .
• Holistic Care: The Nursing and Midwifery Council (2024) emphasises assessing spiritual needs to provide effective holistic care, recognising that "seeing the whole person supports better care" . This aligns with the biopsychosocial model's aim to meet holistic needs and challenges the organisational and practice divisions between mental and physical healthcare .

Effective critique of parity of esteem in mental health nursing necessitates a shift towards models that integrate biopsychosocial, culturally sensitive, and person-centred approaches. These frameworks are vital for fostering equality, social justice, and comprehensive care, moving beyond traditional biomedical limitations to address the full spectrum of patient needs. [Eight references.]

I'll leave it there. I think. PJ

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My emphasis: In the spring I tried to engage and see if I could write a short article about Hodges' model for RCNi. After an online chat and following up by email, Hodges' model isn't for them apparently. It was kindly suggested that I try another journal.

I must improve my prompt writing.

I must improve my prompt writing.

I must improve my prompt writing.

I must improve my prompt writing.

Nurse, you must improve your prompt writing ...

Holistic Bandwidth [II] 16, 180, breadth, depth and thoughts initial

If we were able to put the care record into an appropriate text analysis program is there a measure of the conceptual span - the holistic bandwidth of care - somewhere in there? Could there be a disciplinary or task-based mesh, a tag cloud that could be superimposed on Hodges' model to represent care as holistic bandwidth?

Very early on in the web site's history a page was added on the multicontextual nature of health (and social care). This contexts page like the others has not been properly researched, which I recognise is a risk for readers in terms of 'evidence based sources' and a risk for me since of course the Web is a rather public arena to air initial thoughts.

Since the site and this blog are a call for research in this area, I'm sure a search would reveal a literature, but without recourse to said literature I'm not sure how explicitly - my incomplete - notion of holistic bandwidth has been studied in care contexts. On the context page I included several basic diagrams to indicate how Hodges' model might be used as a 'measure'. This page plus the others need revising with a bin (icon) close to hand, in the meantime how can we measure holistic bandwidth?

We could add the problems identified in each care domains, e.g.:

INTRA-interPERSONAL = 3
POLITICAL = 2
SOCIOLOGY = 5
SCIENCES = 6
= 16

Continuing in a fit of numerics we could throw in some multiplication - 3*2*5*6 = 180 ?
'180' is much more impressive than a paltry '16'.

What next...? Could the domain scores be weighted in some way? Is it valid to assign a primary domain? And while we are at it where does self-care fall (intra-interpersonal surely)? Wither the literary heavyweights of severity, chronicity, strengths, recovery and well-being. ...? Oops - how could I forget - dependency measures are nothing new; but the literature bearers are not the issue.

If we still frequently fail to deliver holistic care, then what is holistic bandwidth (actually measuring)? Is it -

• The scope of care [in one or all of - assessment, planning, intervention, evaluation, outcome]?
• Simplicity [breadth]?
• Complexity [breadth and depth]?
• (Rapid) care integration [time, connectedness]?
• Concordance: clinical problems + patient (carer) problems + outcome set?
• ....?

Holistic care 3: Location

Through February and March I looked at holistic care definitions and other aspects. Now for location.

The place to look for holistic care is literally everywhere. Every - where?

Well yes, if we take holistic to really mean holistic.

There is the obvious physical where that applies in the various care sectors such as; primary, secondary, community and tertiary care and the places they all encompass and contain. The locations associated with buildings and other architectural and organisational structures however permanent: hospitals, hostels, surgeries and clinics, homes, schools, prisons, refugee camps and workplaces - including inner and outer space.

The other where comprises the cognitive and virtual. Our thoughts about care, the thought processes and conscious decision making about care assessment, planning, intervention and evaluation. Except in specific psychoanalytical therapies the unconscious is a less frequently acknowledged and yet undoubtedly factor. If values are to have an origin and a safe harbour (governance) then a light must be cast on the darker, uncertain places. Accepting and utilising these places facilitates a holistic perspective, an adjunct to the more usual analytically derived views.

Speaking of analytical: recently, working on a 2nd temporary secondment, I've been preoccupied (and still am) with PROCESS and CONTENT. We tend to lose ourselves in process; the nursing process, care process, process mapping workshops abound. The problems take centre stage and because they are the patient's problems that qualifies the process as being person-centred. A tick goes in the box.

At times outside of medical emergencies this may be a mistake.

In deploying 'IT' the argument goes that the benefits of information technology in health care (various reports, effective case management, safer practice...) should be transparent, that is -

a by-product of the care process: not an add-on.

To me this suggests that the care process, the energy spent negotiating the care pathway produces a reaction. Informationally this reaction can be desirable. (I'll leave you to contemplate the alternative.)

If the person is truly at the centre of care then maybe the reaction can also be characterised as precession? Just as the Earth precesses on its axis, so our care processes result in precession around the person - the 'whole' individual and their situation at the centre of care?

But only IF we choose to take notice, factually, emotionally and informationally.

There's no disputing that care is frequently wobbly. But this oscillation can provide a periodic peek into the four (5) care domains.

At times these presentations, or windows of opportunity may be physically and emotionally draining, and arise in a highly disordered manner, they are nonetheless there.

Allied with a problem space, that other for me essential location of holistic care, you have a potentially very powerful tool.

I know this may be twaddle and I may be on shaky ground, but at least I'm trying to follow the wobble...

As highlighted previously there are alternate ways of seeing.

Before I close and follow a countdown: Thank you Darcy - a star on stage : GO STS 117 stars in space.

Holistic Bandwidth [I] - Where's the brush?

Apart from those intervals and instances (times!) when emergency intervention is needed, holistic care is seen as a primary goal in health and social care theory, practice and policy.

IF care is not holistic THEN it could be argued that there is care dissonance.

The high quality non-critical, general efforts in the PHYSICAL [SCIENCES] care domain -

fluids, diet, warmth, pressure sore care, comfort, security, infection control ....

can be compromised by lack of attention to the EMOTIONAL [Intra-INTERPERSONAL] care domain -

respect, empathy, unconditional +ve regard, non-judgemental attitude, time, space, attention ....

- what the patient (carers and others*) expect to follow does not occur.

Rather like cognitive dissonance acute discomfort results when care of the required high quality (holistic, timely, person-centred...) is not applied across the board (h2cm).

(In being human) everyone recognises the BASICs of CARE (discuss?):

It is the remembering that is the problem.

Remembering demands an assured space in the organisational memory - such that staff in those other spaces - wards, clinics, patient's homes, residential homes are able to fulfil the holistic spectrum of care needs.

Dissonance encourages game playing with beliefs [1-n players].

It is very easy and a fairly well understood human trait for us to become pre-occupied with what we do. (As you will have noticed I have a problem with brackets and italics...) When at work (i.e. not day-dreaming) "It is what we do that counts."; but care variances bound to professional disciplines and particular clinical settings should not be wielded as a foil.

So, perhaps this dissonance can be represented as distance:

• patients and carers may not articulate their discomfort - at the time

(and hence is perceived of less consequence to the service - at the time);

• as the distance between concepts and their meanings.

Could this distance provide a measure of holistic bandwidth? No doubt, it already has somewhere in the literature? The first holistic bandwidth metric suggested above is acknowledged in policies around the response to complaints, which stress the need to deal with the complaint there and then if possible. Is this enough and what about the distances between concepts and meanings?

more to follow....

I Googled 'organisational dementia' and found the following reference:
‘Sustaining New Industrial Relations in the Public Sector: The politics of trust and co-operation in the context of organisational dementia and disarticulation’ (with M. Martinez Lucio), in P. Dibben, P. James, I. Roper, and G. Wood (eds.) Modernising Work in Public Services London: Macmillan. 2007.

*There is probably a major cost on staff morale here also.

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

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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

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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

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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

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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?)

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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

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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

Interested in writing? [ II ] Hodges' Health Career - Care Domains - Model

In the side bar beneath the bibliography (on a desktop) I've listed a few topics worthy of critical attention. The real need is to link practical application of Hodges' model and further some theoretical underpinnings for the model. This is now happening and it's quite a challenge as I chase questionnaires and write up a draft report for next week. This report is set out as a paper using an author's template from a nursing journal.

Trying to get the message out on writing about this free, holistic bandwidth defining, holistic wrangling, (self-) caring info-portal I blogged an appeal of sorts in 2010. Here we are again. The existing topics in that list relate to the original purposes of the model, plus a few 'extras':

• reflection;
• curriculum development;
• case formulation;
• holistic care;
• conceptual spaces

I'll revise the above as a result of this post and ongoing studies at Lancaster University. I will also add the journal to the most recent recovery paper. Expanding on the above for the benefit of anyone interested in using Hodges' model, reflection (as in 2010) is for me the primary purpose of the model.

Reflection: I'm sure that Hodges' model can complement existing and established approaches to reflection. It would be interesting to compare the use of Hodges' model with a control in clinical reflection, reflective practice with a patient/client, and in clinical or managerial supervision. (You see why this is a challenge, and I appreciate it is easy to generate suggestions!)

Curriculum development: If you need a map that incorporates an academic compass (sat-nav even) look no further. Where are the curricula hot-spots and how are they distributed?

Case formulation: There is an existing draft that needs to be revisited at some point, but the scope here is huge in terms of disciplines and applications. As mentioned above it is coming up with questions and research methods.

Holistic care: Is it time to revisit this phrase? Break it apart and put it back together if it still fits?

Is it a case of damaged goods?

Is this a broken currency as it originally did not include the patient as an active participant? Is it one of several linguistic tropes, said in earnest yet what does it mean? How do we measure it? Could there be a role for Hodges' model in defining or measuring it in theory (through the health record) in practice through outcomes that are demonstrably holistic? Does this make sense...? What is this holistic bandwidth that PJ witters on about? Is an informatics metaphor too far, or this a means to a definition?

To conceptual spaces I need to add threshold concepts and there is a literature here for health and social care, something to build upon and post here....