The Sciences: Points, lines, angles and perspectives on Domains

In Hodges' model the axes are presented - by convention - as perpendicular. From this it follows that the resulting four domains, or quadrants appear as equivalent in terms of the space they each occupy. There are many posts on the blog that present a 2x2 table. When in template form Hodges' model is also a potential corpus, empty apart from its structure, then there must surely be a gross asymmetry in the SCIENCES domain compared with the others, including the SPIRITUAL. Discuss?

#simplicity #complexity #folktheory #humanities #arts #humanistic #emotion #balance

See also: https://hodges-model.blogspot.com/2026/06/h2cm-domains-symmetry.html

Arriving at Hodges' model via guided discovery ...

Following Brian Hodges’ lead in his notes, I have engaged a great many learners with a guided discussion through the following questions:

Questions	Answers	Outcome/Significance
Who do we care for?	The person, individual, patient, client, carer.The group, family, community, national/global population. The 'duty of care'. The Planet.	It is the individual (guardian) who consents to care. The subject at the top of the vertical axis of Hodges’ model is first identified. It is the person who consents to care (or their guardian); then the group occupies the bottom of the vertical axis.
What do we do to help deliver care?	We attempt - complete tasks and interact in ways that are both mechanistic and humanistic. We use procedures, equipment, devices, technologies, physical interventions; and the self – empathy, rapport listening, being present. Team work with effective communication, coordination and collaboration are also essential.	To care is to act. The horizontal axis is added, with humanistic to the reader’s left; and mechanistic to the right. The axes are then complete, revealing the model’s ‘fixed’ structure. Interdisciplinary can be identified and further discussed.
What skills and knowledge do we need to care for the individual, family and populations?	Here we are concerned with the content of the given situation. This can encompass the whole curriculum and acknowledges experiential learning.	The epistemological and ontological scope and scale of health is revealed from self to planet. The importance of context and situation can be stressed. Including first-aid and its rules and risk assessment. Discussion visits and demonstrates the significance of each of the domains of Hodges’ model and the spiritual to participants. The relevance of Hodges' model to the 21st century, as a bio-psycho-socio-POLITICAL model is emphasised.

Previously: 'Hodges' model'.

How is your Odyssey (thus far ...)?

THE ODYSSEY

As a tool for lifelong learning Hodges' model must be capable of providing a structure through which a narrative can woven. A person's career, as in work, is another distinct example. And again the 'health career' through health, illness, physical and mental trials and tribulations is perhaps the prime example. As the example, it forms the basis of myth underpinning the world's cultures, pre- and ancient histories.

Tomorrow, is the day of "Two Odysseys". No: this is not 2001, 2010, 2061 or 3001.

One odyssey, heads off to the South West, to a place where the land ends, apparently. Memories to be made, a story to unfold.

The other, is based on a voyage: an incredible tale, an epic journey - the epic (in the west). This ODYSSEY will be found in the cinema (and not on a phone, TV, PC, laptop ...); and vitally also in an amazing book. Recounting, what was originally the oral tale of Odysseus on his fantastical 10-year journey home after the Trojan War.

Hodges' model provides a structure to weave this narrative, the twists and turns of patients, carers, students and personnel - all the narrative forms.

Image: https://www.rottentomatoes.com/m/the_odyssey_2026

See also: The Hero's Journey and Joseph Campbell

Leapspace? Why not ...?

Referred to a paper in an email: https://doi.org/10.1016/j.jclinepi.2026.112401.

- I noticed an invitation to try Leapspace. 

So I leapt (with much editing - for formatting here). ...

 

Copilot steps

Creating a plan to respond to your query

Performing search for foundational documents
Performing keyword search
Using data from Scopus
("Hodges' model" OR "Hodges model" OR "Hodges' health career model" OR "health career model" OR "care domains model") AND (nursing OR healthcare OR "health care" OR education) AND (domain* OR component* OR framework OR concept* OR definition*)

Performing natural language search
Using data from Scopus
What are the conceptual definitions, domains, and components of Hodges' model in nursing and healthcare education?

Performing keyword search
Using data from Full text
("Hodges' model" OR "Hodges model" OR "care domains") AND (diagram* OR figure* OR visual* OR schema) AND (teach* OR education OR curriculum OR learning) AND (critique OR adaptation* OR application*) AND (method* OR framework OR discussion)

Performing natural language search
Using data from Full text
How is Hodges' model represented, taught, and adapted in nursing or healthcare education, including diagrams and critiques?

Performing keyword search
Using data from Scopus
("Hodges' model" OR "Hodges model" OR "care domains framework") AND (application* OR use OR implementation OR practice) AND (critique* OR limitation* OR adaptation* OR evaluation*) AND (nursing OR healthcare OR "health care")

Performing natural language search
Using data from Scopus
What applications and critiques of Hodges' care domains framework have been reported in nursing and healthcare practice?

Done

Generated by LeapSpace, Thu Jul 09 2026

Hodges' health career - care domains - model

Hodges’ Health Career – Care Domains – Model is a generic, practice-based conceptual framework for health and social care that organizes thinking into four knowledge/care domains: science, political, sociology, and interpersonal. It is presented as broadly applicable across healthcare contexts and is used to structure reflection, critical thinking, and care planning. [1] [2] [3]

Core domains

Domain	What it covers	How it is used
Science	Cause and effect, evidence, costs, benefits, and trade-offs	Helps frame the “hard” evidence side of care and service decisions. [1]
Political	Policy, systems, and structural influences on care	Helps connect care to wider health and social policy contexts. [1] [4]
Sociology	Social context, culture, stigma, and relationships	Helps explain how social factors shape health and illness experiences. [1] [5]
Interpersonal	Therapeutic relationships, patient/carer engagement, and human interaction	Supports person-centred and relational practice. [1] [2] [6]

What the model is for

• It is described as universal in structure and adaptable to many healthcare settings, including informatics, dementia/palliative care, forensic mental health, and oral health. [2] [3] [4] [7] [8]

• It helps practitioners map concepts into domains, build a mind-map-like structure, and support reflective practice and critical thinking. [3] [9]

• In forensic mental health nursing, it is proposed as a way to guide assessment, decision-making, and recovery-oriented practice. [2]

Bottom line

Hodges’ model is best understood as a four-domain lens for integrating clinical evidence, policy, social context, and relationships into one framework for care and reflection. Its main value is not in prescribing a single care process, but in helping users think more holistically and systematically about health problems and care systems. [1] [2] [3]

Confidence level: High — multiple sources consistently describe the model’s four domains, generic structure, and broad healthcare applications.

References

1. Fox, Siobhán, FitzGerald, Carol, Harrison Dening, Karen, (...), Timmons, Suzanne (2017) Better palliative care for people with a dementia: summary of interdisciplinary workshop highlighting current gaps and recommendations for future research. BMC Palliative Care. https://doi.org/10.1186/s12904-017-0221-0

2. 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. https://doi.org/10.1111/j.1365-2850.2012.01961.x

3. Jones, P., Wirnitzer, K. (2022) Hodges' model: The Sustainable Development Goals and public health - Universal health coverage demands a universal framework. BMJ Nutrition, Prevention and Health. https://doi.org/10.1136/bmjnph-2021-000254

4. Bettiol, S., Jones, P., Onyedikachi, H.A., Kernohan, W.G. (2026) Bridging Gaps in Oral Health Frameworks: Mapping With Hodges' Health Career - Care Domains - Model. Journal of Public Health Dentistry. https://doi.org/10.1111/jphd.70034

5. Jones, P. (2008) Exploring serres' atlas, Hodges' knowledge domains and the fusion of informatics and cultural horizons. Social Information Technology: Connecting Society and Cultural Issues. https://doi.org/10.4018/978-1-59904-774-4.ch007

6. Merritt, M.K., Procter, N. (2010) Conceptualising the functional role of mental health consultation-liaison nurse in multi-morbidity, using Peplau's nursing theory. Contemporary Nurse. https://doi.org/10.5172/conu.2010.34.2.158

7. Jones, P. (2009) Socio-technical structures, 4Ps and hodges' model. Nursing and Clinical Informatics: Socio-Technical Approaches. https://doi.org/10.4018/978-1-60566-234-3.ch011

8. Jones, P. (2011) Socio-technical structures, 4Ps and hodges' model. Clinical Technologies: Concepts, Methodologies, Tools and Applications. https://doi.org/10.4018/978-1-60960-561-2.ch215

9. Jones, P. (2025) A Generic Model and Conceptual Framework to Prime Curiosity Across Health and Social Care Disciplines to Facilitate Lifelong Learning. Journal of Evaluation in Clinical Practice. https://doi.org/10.1111/jep.70252

Follow-up Suggestions 

What are the key components of Hodges' health career care domains model?

How does Hodges' model apply to interdisciplinary health care practices?

What are the implications of Hodges' health career care domains model for patient-centered care?

Where is the Centeredness of Care?

In trying to see Hodges' model anew, which is quite a challenge after four decades; what of the model's structure?

It is easy to get carried away with mathematical terminology:

One line, add another, and they intersect, at a 90 degree right angle. So is centeredness to be found at the intersection point? 

If I'm tying myself up in knots well there's another possibility! 😉 

As a whole it appears the axes of the model are a manifold and not - in the center?

What do you think?

See also: 'What Is a Manifold?'

https://www.quantamagazine.org/what-is-a-manifold-20251103/

[Updated] AI Chat: Are the domains of Hodges' model comparable?

In drafting a future post: 'The Sciences: points, lines, angles and perspectives on domains', I thought I would ask Ecosia's AI Chat a related question, here is the (quick) prompt and reply:

PROMPT: 
In Hodges' model there are four care, or knowledge domains. The four domains are the sciences, sociology, political, and intrapersonal – interpersonal domain. In terms of potential content are these domains comparable, or is there an essential asymmetry? Please provide sources and references.

(I have saved the prompt for future reference and refinement.)

RESPONSE: [updated 21st June 2026]

Hodges’ model (also known as the Health Career Model or h2cm) is a conceptual framework that organizes knowledge and care into four quadrants, each representing a distinct domain of human experience and knowledge. These domains are:

1. Sciences (empirical, biological, and physical sciences)
2. Sociology (social structures, relationships, and community)
3. Political (power, policy, governance, and resource allocation)
4. Intrapersonal – Interpersonal (psychological, emotional, and relational aspects of the self and others)

Are the Four Domains Comparable or Asymmetrical?

The four domains in Hodges’ model are not strictly symmetrical in terms of their content, scope, or application. While they are presented as equal in structure (each occupying one quadrant of the model), their potential content, theoretical foundations, and practical implications can vary significantly. Here’s why:

1. Differences in Scope and Focus

• Sciences (Quadrant 1):
  This quadrant focuses on empirical, measurable, and biological aspects of health and care, such as anatomy, physiology, and pathophysiology. Its content is often highly specialized, technical, and evidence-based, rooted in natural sciences like biology and chemistry.

  • Example: The role of hormones in stress response or the pathophysiology of diabetes.

• Sociology (Quadrant 2):
  This quadrant addresses social structures, culture, and community dynamics. Its content is broader and more interpretive, drawing from sociology, anthropology, and social psychology.

  • Example: The impact of socioeconomic status on health outcomes or the role of family support in recovery.

• Political (Quadrant 3):
  This quadrant examines power, policy, governance, and resource distribution. Its content is highly contextual and often contested, influenced by political science, economics, and public policy.

  • Example: The effect of healthcare policies on access to services or the role of advocacy in shaping health priorities.

• Intrapersonal – Interpersonal (Quadrant 4):
  This quadrant focuses on individual psychology, emotions, and relationships. Its content is highly subjective and variable, drawing from psychology, psychotherapy, and ethics.

  • Example: A patient’s personal beliefs about illness or the dynamics of a therapeutic relationship.

2. Differences in Methodology

• Sciences and Political domains often rely on quantitative methods (e.g., experiments, statistical analysis, policy evaluations).
• Sociology and Intrapersonal domains frequently use qualitative methods (e.g., interviews, case studies, ethnography).
• This methodological diversity can create asymmetry in how knowledge is generated, validated, and applied.

3. Differences in Practical Application

• Sciences and Political domains  are often system-level and influence macro-level decisions (e.g., clinical guidelines, healthcare policies).
• Sociology and Intrapersonal domains are more individual- or community-level, focusing on personalized care, cultural competence, and therapeutic relationships.
• This can lead to asymmetry in impact, where some domains (e.g., Political) shape broad systems, while others (e.g., Intrapersonal) focus on direct human experience.

4. Theoretical Foundations

• The Sciences and Political domains are grounded in positivist and structuralist theories, emphasizing objectivity and external reality.
• The Sociology and Intrapersonal domains are influenced by interpretivist and constructivist theories, emphasizing subjectivity and lived experience.
• This theoretical diversity can create asymmetry in how knowledge is perceived and valued in different contexts.

Is There an Essential Asymmetry?

Yes, there is an essential asymmetry in the potential content of the four domains. While the model presents them as equal in structure, their content, methods, applications, and theoretical foundations are not interchangeable. The domains complement each other but serve different purposes in understanding and delivering care.

Sources and References

1. Conceptual Overview of Hodges’ Model:

   • Hodges’ Model: A Cognitive Periplus for - WikiEducator (PDF)
   • Hodges’ Model: Welcome to the QUAD
   • Hodges’ Health Care Model as a Framework for Quality

2. Theoretical Foundations:

   • Hodges’ Health Career Model and its role and potential application
   • Hodges’ model: the Sustainable Development Goals and public health

3. Discussions on Asymmetry and Complementarity:

   • The model’s holistic intent is emphasized in Hodges’ Health Care Model as a Framework for Quality, but its quadrants are not identical in content or application.
   • The differences in methodology and scope are discussed in Hodges’ Health Career Model and its role and potential application.

Summary Table: Asymmetry in Hodges’ Model Domains

Domain	Content Focus	Methodology	Theoretical Foundation	Level of Application
Sciences	Biological, empirical data	Quantitative	Positivist	Macro (systems, clinical)
Sociology	Social structures, community	Qualitative/Quantitative	Interpretivist, Structuralist	Meso (groups, communities)
Political	Power, policy, governance	Quantitative/Qualitative	Structuralist, Critical Theory	Macro (systems, policy)
Intrapersonal-Interpersonal	Psychology, emotions, relationships	Qualitative	Constructivist, Humanistic	Micro (individual, relational)

PROMPT: 
In Hodges' model there are four care, or knowledge domains. The four domains are the sciences, sociology, political, and intrapersonal – interpersonal domain. In terms of potential content are these domains comparable, or is there an essential asymmetry?

 

In Hodges’ model, the four care (or knowledge) domains are:

1. Sciences (biological, physiological)
2. Sociology (social, cultural, environmental)
3. Political (legal, policy, organizational)
4. Intrapersonal – Interpersonal (psychological, emotional, relational)

These domains are not strictly comparable in terms of content, scope, or function. Instead, they represent complementary perspectives that together form a holistic framework for understanding human health, well-being, and care. Here’s why there is an essential asymmetry between them:

1. Scope and Focus

• Sciences and Sociology are broad, well-established academic disciplines with extensive theoretical and empirical foundations. They provide generalizable knowledge about biological processes and social systems.
• Political is more narrowly focused on power structures, governance, and resource allocation. While critical for systemic change, it is less about individual experience and more about collective frameworks.
• Intrapersonal – Interpersonal is deeply personal and subjective, focusing on individual psychology, emotions, and relationships. It is less about universal laws and more about unique, context-dependent experiences.

This makes the intrapersonal-interpersonal domain inherently asymmetrical compared to the others, as it deals with subjectivity and variability rather than objective or structural phenomena.

2. Epistemological Differences

• Sciences, Sociology, and Political domains rely on external observation, measurement, and analysis. They are rooted in positivist or structuralist traditions, where knowledge is often generalized.
• Intrapersonal – Interpersonal is rooted in interpretivist and phenomenological traditions, where knowledge is co-created through subjective experience and dialogue. It resists universal generalization.

This creates a fundamental asymmetry in how knowledge is produced and validated across the domains.

3. Practical Application in Care

• The Sciences, Sociology, and Political domains provide frameworks for action (e.g., medical treatments, social policies, legal rights). They are instrumental in shaping systems and interventions.
• The Intrapersonal – Interpersonal domain is transformative—it shapes how individuals perceive, interpret, and respond to care. It is the domain where meaning is made and agency is exercised.

This means the intrapersonal-interpersonal domain is not just another “content area” but a lens through which all other domains are experienced and integrated.

4. Hierarchy of Integration

While the domains are conceptually equal in Hodges’ model, in practice, the intrapersonal-interpersonal domain often acts as the nexus where the other domains intersect. For example:

• A scientific understanding of depression (e.g., serotonin levels) must be interpreted through the intrapersonal experience of the individual.
• A sociological analysis of healthcare disparities must be understood through the political structures that enable or inhibit change.
• A political decision about resource allocation must be filtered through intrapersonal values and priorities.

This integrative role makes the intrapersonal-interpersonal domain asymmetrical in function, even if not in formal status.

Conclusion: Essential Asymmetry

The four domains are not comparable in content or function. Instead:

• The Sciences, Sociology, and Political domains provide structural and systemic knowledge.
• The Intrapersonal – Interpersonal domain provides subjective and relational knowledge, which is essential for meaning-making and agency.

The asymmetry arises from the epistemological and practical differences between objective/systemic knowledge and subjective/experiential knowledge. Hodges’ model emphasizes that all domains are necessary, but they operate in fundamentally different ways.

iii Book: 'Complexity in Health Care - A Paradigm Shift for Clinical Practice'

In reading this book and others on W2tQ, I must make the following points:

  * my need to remember the purely USA context (I have never worked there);
  * my healthcare, nursing, informatics experience is NHS-based;
  * this review (and others) is motivated by the project here - Hodges' model;
  * as a result, I will be quoting heavily, there is much to bring to your attention.

As noted in post (i) there is much to whet the appetite, a paradigm shift, 'comprehensive, collaborative, and integrated care' (p.11) certainly have become popular topics in the medical literature. Not only that but 'interpersonal and intersubjective treatment models' too (p.12).

The role of 'Case Managers' is highlighted, plus the Case Management Society of America, which is committed to:

•  Improved Consumer Health Outcomes
•  Professional Diversity, Equity, and Inclusion
•  Cultural Competency and Humility
•  Advocacy for the Health Consumer
•  Integrity and Ethical Principles
•  Promoting Health Equity
•  Educating Case Managers Across the Care Continuum
•  Evidence-based Quality Care
•  Holistic, Compassionate Care
•  Fostering Communication and Collaboration
•  Advancing Research, Innovation, and Use of Technology
•  Fiscal Accountability [ https://cmsa.org/about/ ]

Whether the USA influences global trends in the structure and form of healthcare is another post, but there is a UK Case Management Society too: https://www.cmsuk.org. I can see a fit here [UK] with the development in recent decades on social prescribing. A different role, of course but part of a complex jig-saw.

As expected definitions are provided: 

'Roger Kathol has eloquently defined "health complexity" as "the interference with the achievement of expected or desired health and cost outcomes, due to the interaction of biological, psychological, social and health systems factors when patients are exposed to standard care delivered by their doctors" [1].' p.10. 

Roger G. Kathol, Rachel L. Andrew, Michelle Squire, Peter J. Dehnel (2018) The Integrated Case Management Manual: Value-Based Assistance to Complex Medical and Behavioral Health Patients. 2nd ed. Basel: Springer.

I can see where this definition comes from, but for me, it does not sit right. The problem when there is 'interference' is the assignment of responsibility and consequence that blame can follow. We've seen this, and in mental health too), with the recover model^. Some of the terms here may be completely innocuous politically speaking (which is the author's intent of course), but they can also be 'weighted'. Hence they can become concrete terms of judgement. Think about it: achievement, expected, desired, cost (and) outcomes, standard care, delivered (by doctors)? Or, am I over-thinking again.

In the margin I pencilled/drew:

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

Standard -	care
Other -	factors

As ever, the individual patient is our focus. The individual is supported (literally) by the social and political (infra-)structures that act as a scaffold, safety-net for most.

Time flies, I can't believe it was 2007 I posted 

Plush HQ foyer, shame about the mannequins!

I had this notion of life-size cardboard cutouts representing the average people who use a given health service provider (local, or not so local these days?). The data will be there in statistical annual reports. I'd noticed the displays - analogue and digital that greeted visitors at a local NHS Trust HQ. This would be the book's 'routine patients' who receive standard care. 

Chapter 3 introduces 'variables' which again is brief, but imporant as variables recur throughout the book. The 'Clinical Field' is first outlined, as in:

• Sources of clinically relevant factors;
• Dynamic factors;
• and: Variables representing contributions from practitioner(s).

Abstract variables are differentiated from those that are concrete. It's reassuring to read there is no true simplicity within the clinical field, and the author's goal is to 'unpack complexity so it remains as true to life as possible, not just manageable conceptually.' p.18.

Frankel et al. are primed to go beyond this. Maths, as in statistical procedures are one tool. Chapter 4 adds to this with a theoretical model to guide clinical understanding of patients with biopsychosocial complexities, the foundations of our paradigm shift. p.23.

If you have an understanding of Hodges' model you can picture my response to this. But, staying grounded, the whole book and paradigm shift represents a form of scientific "emergence". It is frustrating that literature searches fail to pick out Hodges' model. 

Frustrating too as reading of "awe", also on page 23, I have experienced this many times (over say 1977 - 2019 ...). So, I held on to my dummy (pacifier!?) and read on ...  

Chapter 4 Technical Considerations is one the longest and contributes all of Part III. Here you can read about science, measurement, statistics, empirical, operational definitions, intelligence, reliability. I often see a chapter, book section as a useful primer for students and the same applies here; with inter-judge realiability, validity, control, null hypothesis, statistical methods and much more. Reference to mathematics (axiomatic too) had me hoping for more. I picked out Structural Equation Modelling:

 'We would also like to suggest that following the steps involved in "structural equation modeling" (path analysis) is a good way of conceptualizing and reasoning about complex clinical variables altogether. For example, constructing a clinical model informally (intuitively, loosely from data) and thinking about (diagramming) how the variables involved may moderate and mediate each other can be a useful activity for clarifying the nature and requirements of a complicated clinica1 situation. 
 

 In simplest terms, an independent variable is the causal or influential variable that impacts and effects the dependent variable. A moderating variable is a dichotomy, and refers to two comparison groups (e.g., male/female; passed/fail; religious/nonreligious; tall/short; high versus low socioeconomic status) that display significantly different degrees of magnitude on a correlated relationship. For example, the relationship between a specific treatment for a medical disorder and treatment outcomes may be moderated by socioeconomic differences. The treatment outcome relationship may be stronger and more positive for individuals with elevated socioeconomic standing who therefore have better support systems and access to medical professionals, and fewer economic stressors.' p.36.

I think from this the authors might be sympathetic to giving 'life' to the POLITICAL domain and Hodges' model; after all it lives in people's daily experience - acknowledged or not. The book's structure works thus far: Chapter 5 Nature-Nurture (n.b. no escape!)  and the Epigenome. The structure - flow - works, as at just over four pages, it begs further reading (beyond the listed references). I still have my copy of:

Fritjof Capra and Pier Luigi Luisi (2014) The Systems View of Life - A Unifying Vision. Cambridge: Cambridge University Press.

 

With the epigenome being added to the 'patient complexity equation' in chapter 5, I wondered whether this was predictable, a promise, or a tease?

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

nature?	NATURE?
NURTURE?	nurture?

 

Previously: 'complex' : 'nature' : 'mental health' : 'person(-centred)'

More to follow ...

^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. 

Steven A. Frankel, Steven D. Thurber, James A. Bourgeois (2023) Complexity in Health Care: A Paradigm Shift for Clinical Practice. Cham. Switzerland: Springer. ISBN: 978303114948.

ii Book: 'Complexity in Health Care - A Paradigm Shift for Clinical Practice'

I didn't have time to finish reading Frankel et al. before WCCS26. This book has an index which was very useful, to efficiently check certain points. It is amazing the number of books without an index.

Chapter 1 is 'Guiding Principles' and links really well with the index. At two pages it is brief and yet also constitutes Part 1. 

Part II The Clinical Situation, continues an introductory thread. Chapter 2 The “Clinical Situation”: An Introduction to Its Structure and Complexity is what attracted me to the book. At five pages, there was more in this vein. I looked ahead and found that the chapters all seemed short. Checking the book's web page, 50 chapters in 270 pages, so just over 5 pages and well referenced too.

Initially, you might feel short-changed, of course, I didn't with a review copy. But don't worry. You are in patient- person-centred hands here. Sometimes content matters. The three authors work and are researchers in psychiatry. For me, the guiding principles and part II provide a handshake with the index. The person here then, is given a literary hug. Immediately, there is a link between the variables of care and the structure of a case (or caseness). 

'But importantly that "structure" is dynamic changing over time. We classify variables as "clinical" as they are brought into play for the purpose of treatment, i.e., the goal of healing.

The clinician is not just challenged to unravel this complicated situation but also to represent the patient accurately, including his or her "human" elements as represented by temperament and personal attitudes. What are the patient's essential needs. tolerances, preferences? Yet, there is even more to know about each patient. Does she have children? What is her financial status, her ethnicity? What are her attitudes about medical professionals. Does she believe in medicine, or even in science?

Beware! None of these factors are dispensable when trying to understand a patient. Just try to leave out a few and you are left with a gutted rendering of that person, not a living human being.' p.7. 

(and continued in fragmented form below ...)

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

'The result even when this level of detail, is available may still be an anemic version of the patient.    Traditionally a medical patient is subjected to an extensive workup that includes a mental status examination, in addition to a detailed past and present history, ...	... and an extensive "review of (organ) systems.
Now add the multiplicity of problems, psychiatric and systemic medical, from which the patient suffers. ...	Multiplicity may include systemic medical, psychiatric, social, financial, and lack of access to health providers.' p.7.

'From this description it seems logical that complex patients presenting with mixed medical-psychiatric disorders be managed with an ongoing collaborative approach delivered by a multispecialty team. Included may be a primary care physician, psychiatrist, and/or psychotherapists. One or more of the collaborating professionals may be a nurse practitioner and/or a physician's assistant.' p.7

I will return to the 'logical' in the final quoted paragraph above. The author's declare their intent from the outset, and by the literature-to-date they achieve this (may I please add? 'in spades!').

 

Over the years and as raised on W2tQ, several colleagues and contacts have asked "Where is the book on Hodges' model?" Not to sound weird, but this book asks that same question through some challenges to the usual 'medical' text. There are several lessons to take away here, even if only to keep a dream alive. While the physical size of a textbook, its practical appeal and stance makes it appear as something to pop in your top shirt/jacket pocket. A pocket guide: quite an impression just 10-20 pages in, and in this digital age.

 

As you would expect from mental health practitioners - psychiatrists - psychotherapists, interpersonal, subjective-objective and intersubjective factors are integral to how complexity is defined and measured. In Chapter 2, pp.11-12 there is mention and reference to the Value-Based Integrated Case Management Complexity Assessment Grid:

Specker, S., Andrew, R., Drexler, E., Koithan, E., Thurber, S., & Frankel, S. (2026). Development of the Self-Administered Health Complexity Screening Instrument. Professional case management, 31(2), 81–89. https://doi.org/10.1097/NCM.0000000000000845

I will check this instrument as I complete this review. As noted on April 9th this book was published in 2023, so I remain grateful to Daniela and colleagues at SpringerNature for the review copy (which also enjoyed WCCS!).

Previously: 'complex' : 'holistic bandwidth' : 'mental health' : 'person(-centred)'

More to follow ...

Steven A. Frankel, Steven D. Thurber, James A. Bourgeois (2023) Complexity in Health Care: A Paradigm Shift for Clinical Practice. Cham. Switzerland: Springer. ISBN: 978303114948.

The alchemy of terminology, symbols, and signs ...

Or, 'What is a nurse doing … in a chemistry class?' [Ack. See Estrada]

In reading, I was reminded that chemistry adopted mathematical symbols for its own use. Not only that, but as a core science (with physics and biology, emerging from natural philosophy) there is a historical development from the time of alchemy:

Please see (with a graphical abstract):

C.Wentrup, The Transition from Alchemical to Modern Chemical Symbolism: from Bergman and Guiton de Morveau to Hassenfratz and Adet, Higgins, Richter, Dalton, and Berzelius. ChemPlusChem. 2024, 89, e202400033. https://doi.org/10.1002/cplu.202400033

This journey matters today as the use of symbols, in mathematics or other fields can be a barrier to learning and hence personal and disciplinary progress:

Ollie Hunter. Lost in translation: Demystify scientific symbolic language to help your chemistry students overcome any potential learning barriers. Royal Society of Chemistry, 23 May 2022.

As acknowledged many times, it is easy to take a word, or concept from one discipline and 'fit' it to - or in another. Or is it? Estrada concludes:

“The complexities of modern science and modern society have created a need for scientific generalists, for men trained in many fields of science.” This is a paradigm of science in the XXI century, where the advent of such fields like the study of complex systems requires multidisciplinary approaches. But the previous phrase was not written in the XXI century. It is the starting sentence in The education of a scientific generalist” published in Science in 1949 (Bode et al. 1949).' p.161. 

'Mathematics has been defined as the science of patterns. Thus, mathematicians search for “numerical patterns, patterns of shape, patterns of motion, patterns of behavior, voting patterns in a population, patterns of repeating chance events, and so on” (Byers 2010). Once a pattern is identified either in chemistry or in mathematics, the researcher can proceed to the clarification of the systematic rule which is behind that pattern. This is evident in the analogy used here between code-breaking and structure elucidation. This attachment to patterns makes both chemists and mathematicians very prone to the use of pictures. An organic chemist hardly can say anything about the chemical reactivity (or any physical or chemical property) of a molecule from its exact quantum-mechanical Hamiltonian. However, she will construct a complete narrative about the physical and chemical properties of a molecular structure drawn in a piece of paper, even if such a molecule is completely imagined. The power of pictures in mathematics is discussed in the book Mathematics and the Unexpected by Ivar Ekeland (1990) where its value is recognized as fundamental in the early stages of the development of mathematical ideas. This also introduces a very important analogy among chemists and mathematicians. Namely, that they use a proper language in their respective fields. While physicists use the mathematical language in their investigations, chemists use the sophisticated language of chemical formulas and specific symbols to represent charges, rearrangements, partial equilibria, etc. These “invented” languages mainly appear only in Chemistry and in Mathematics, making them unique intellectual activities.' p.162.

With thanks to the author, Ernesto Estrada IFISC for additional thoughts and insights:

Estrada, E. What is a mathematician doing…in a chemistry class?. Found Chem 26, 141–166 (2024). https://doi.org/10.1007/s10698-023-09497-4

Wittgenstein's - Tractatus

Apparently, Wittgenstein walked away from philosophy after publication of the Tractatus. He thought he had solved the problems of philosophy, logic and reality.

In trying to ‘see’ Hodges’ model, in mathematical terms, there may be lessons in Wittegenstein’s approach, both in content and style. Of course, as a non-mathematician, I probably should leave well-alone; and stick to nursing. But that is the problem: from 1987-88 there is a need for a different perspective, even if this is a personal challenge. As with many ‘reviews’ here, we can look at Wittengenstein’s work, reflect upon it, and consider how it relates to the purposes, structures and content of Hodges’ model.

The Tractatus’s first line then, offers a warm welcome.

‘The world is everything that is the case.’ [I]

Making the decision to become a nurse and enrolling as a student makes you an educational and workforce demographic case.

Once a student in the university lecture theatre, you hopefully whether consciously, or not are exposed to the theory – practice gap; as you yearn to be on your first placement. Now it you who is seeking ‘cases’. As we live, and statistics roll and tally, the question of caseness (and categories) is key, one that is carried around even if not always active, recognised as such.

As noted in the previous post, we can for Hodges’ model (and other models, frameworks it must be said) think of ‘case’ as a, or the situation. 

A mathematical approach to Hodges’ model involves looking at things, concepts, people as objects. This includes patients and carers. In terms of a project worthy of pursuing in nursing and other disciplines involved in healthcare, this mathematization presents a non-trivial challenge. A fully-deserved response would be: 'What have you done to the aptitude for care and caring attitude? You've cancelled - subtracted it!' Humour aside:

'In order to know an object, I must know not its external but all its internal qualities.' [2.01231] 

Is this equivalent to us getting to know our patient / client and their socio-political context? 

‘The way in which objects hang together in the atomic fact is the structure of the atomic fact.’ [2.032] 

It is a help that Wittgenstein points to structure (crumbs of understanding are welcome here, as incremental steps). In formulating Hodges’ model we first identify the axes. It is the axes that then provide a space, four domains in total, to frame the objects that we decide; or, as the situation dictates, what concepts are placed in the domains of Hodges' model.

There is a successive series that follows, combining place, space and logic: ‘The proposition determines a place in logical space: the existence of this logical place is guaranteed by the existence of the constituent parts alone, by the existence of the significant proposition.’ [3.4]

‘The propositional sign and the logical coordinates : that is the logical place.’ [3.41]

‘The geometrical and the logical place agree in that each is the possibility of an existence.’ [3.411]

‘Although a proposition may only determine one place in logical space, the whole logical space must already be given by it.
(Otherwise denial, the logical sum, the logical product. etc., would always introduce new elements -in co-ordination.) 
(The logical scaffolding round the picture determines the logical space. The proposition reaches through the whole logical space.)' [3.42]

While Wittgenstein came to view ‘the picture theory of meaning’ as incorrect, as a conceptual framework and diagrammatic resource Hodges’ model is closely tied to this form of representation.

Of course, the logic at work here, is far from mathematical, but there is surely a logic.

'Formal concepts cannot, like proper concepts, be presented by a function.' [4.126]

'There is therefore really a sense in which in philosophy we can talk of a non-psychological I.
The I occurs in philosophy through the fact that the "world is my world'".
The philosophical I is not the man, not the human body or the human soul of which psychology treats, but the metaphysical subject, the limit - not a part of the world.' [5.641] 

'Although the spots in our picture are geometrical figures, geometry can obviously say nothing about their actual form and position. But the network is purely geometrical, and all its properties can be given a priori.

Laws, like the law of causation, etc., treat of the network and not of what the network describes.' [6.35]

There is much more in this work, and much that remains a challenge. Many commentators have written and said in interviews that the Tractatus rewards re-reading and some sentences stay with you for life (The Great Philosophers BBC TV). 

I'm still seeking mine.

https://www.gutenberg.org/files/5740/5740-pdf.pdf

iii Picking up sticks: when axes matter

It is one thing for us to break the stick, but quite another from a concept's perspective. They are accustomed to the dynamics at work, when as search terms they are exploded, or not. And, not just any concept but one that can be unique. Consider the concept, and how or where it finds itself [ in Hodges' or another model ]? Let us use the intra-INTERPERSONAL domain, as an example, and ask:

1. Is 'mood' fixed by the I-axis alone?
2. Does the humanistic axis have a role in where in the doomain the user of Hodges' model places 'mood'?
3. Acknowledging person-centredness, if the patient/client had a view, to what extent would this agree (with annonymity assured) with the professional's judgement, or a relatives / guardian?
4. What is as a result, 'mood' has become 'very low mood'? (To continue in this vein , invites complication, but we will continue.)
5. Introducing the 'Other' whatever their role and relationship, pushes us to the humanistic, but whether this is achieved in a person-centred manner (triage excluded) is a matter of opinion and judgement (evaluation).

If mood is fixed by the I-axis then if we determine the issue is 'low mood' are we introducing a combined quantitative and qualitative dimension, a continuum, at the selected point in the interpersonal domain? Writing previously about threshold concepts, I wondered, and proposed compound threshold concepts. There is a progression from the patient's subjective self-assessment, to in all likelihood of an objective measure being introduced, so spanning two domains. Definition of 'compound' aside; there is a compound structure at work.

What points 1-5 above reveal is triangulation. When it is argued that Hodges' model facilitates navigation as per my presentation on 21st April, this is a strategy from mixed-methods research in practice. Many years ago, Hodges' model was described as a 'cognitive periplus', reflecting the way ancient mariners initially charted the coastlines creating the first map, as per their culture and dispora. In the west more recently the value of social approaches and activities, especially in mental health. Care navigation is a role. Literally sign-posting to individually suited (which must be stressed) activities, resources, and agencies. So, in Hodges' model what are our three triangulation points? They are:

1. Axial;
2. Intra- InterDomain; 
3. Person-centred. 

Perhaps, we can describe 1-2 as conceptual anchors at least when dealing with a concept, while #3 is more about approach, values and philosophy. So, there is something of a 'cheat' going on, because each one is compound:

1. Axial: The axial is comprised of four points. The axes create a Cartesian plane (figure). And, as far as a patient is concerned, they mark off a point on the respective Individual and Humanistic-Sciences parts of the axes. This form of triangulation point can claim a general conceptual precision (language) in the applied terminal labels; but what happens in-between can be patently fuzzy. A mix of what may be objective and subjective.

2. Intra- Interdomain: This may be the most imprecise triangulation point. It appears the axes of Hodges' model are composite (figure). They have two-sides as a boundary. To be pedantic, in our example, one plays to the interpersonal domain, the other the sciences.

[The relationship between the axis and the domains in Hodges' model, is far from unique; but I wonder if there is something else here?]

2. Person-Centred: There is a paradoxical nature to person-centred(ness). It is also nebulous in nature, and yet in care it is definitive in practice (safety, purposes, values, professionalism, competency, ...).  It forms locus which can also be classed as a traingulation point, at the centre of the model. This is the point around which Hodges' model is built. This captures the individual's (life, care) context and situation, all influenced by their life chances as consequent health - and other - careers. Salience and our attention^ is key. Is it possible to frame our purpose(s)?

^A focus for [N] autumn.

Marrakech, Le Jardin Secret. 24th April. 1000-1830.

Picking up sticks: when axes matter ii

This past week at WCCS26, I've put Hodges' model itself on the work-, or more properly the inspection bench. Now, referring back to the - 'Our broken sticks' c/o Roger Lewin "Complexity: life at the edge of chaos" post, perhaps a theatre table is required. That is, as I try to examine the model, take it apart, have a look at the bits - as far as they are. And, what about the question posed in the above post?

'If we take the axes of Hodges' model, and break them at twenty-five points, I wonder what we end-up (or start) with?'

If there are twenty-six sticks, well, amongst other things - we've made quite a mess. But, there's more going on.

There may be some kind of idealised symmetry, or is it equality between the necessary, or projected length of the I-G axis. That is, as it extends for the INTERPERSONAL and SOCIOLOGICAL domains. But is there equivalence, in a default sense, for the SCIENCE and POLITICAL domains? Or am I (once again) overthinking? If medicine, health and by implication social care are bio-psycho-social, then surely we have a structural problem? Not only that, but we see a boundary, partition ... axis - in action. In Hodges' model the axes have two parts, two sides, so they are in effect composite. If the bio-psycho-social model is true, in whatever senses we wish to declare, derive or pursue in research (the literature, logic, practice, political expediency, or realism ...), then the group axis is incomplete. 

Hodges' model: Structure and Content - Axes and Domains

Is this literally why health care systems are so difficult to design, develop, establish and sustain? Think about that too, please. Is this why we as individuals rely on a functioning (caring) society and political systems? Is this why health care systems can suddenly be faced with collapse, as geopolitics has revealed. Vulnerability, becomes more than an individual characteristic and experience; when nations are dependent upon others for their funding, organisation, logistics, personnel, continuity and more. As a result, many understandably want to break with this socio-political and coloanial legacy.

Is there something in the sentence above in italics, that we can actually utilise to help define the foundation of Hodges' model? Again, not wanting to sound grandiose, but is there an axiom hidden in there? Even as 'health' is the inevitable election issue. The irony of this! Even if the politics of health and health in politics is not so much hidden as often denied. History reveals the influence of triage on the battlefield on the emergence of medicine and surgery. The future is here now. There is a political fight to follow for health in all its manifest forms. So here is another post to return to.