'Problem patients?' 1 - Wimps and space to care

I responded to a mail list discussion around 'problem patients' which began with the following main points:

• a relatively new nurse
• surprise that a significant minority of (my) patients are pathological wimps;
• even prior to seeing them they can often easily be spotted by examining their medical records;
• for example, I frequently notice that wimps have an obscene (and often downright odd) amount of special meal requests;
• current nursing philosophy encourages nurses to be endlessly supportive of wimps. i.e. to follow the often demonstrably wrong idea that "the patient is always right.";
• IMO nurses who claim they benefit such patients using the current model of appeasement based care are co-dependent personality types who enjoy feeling needed more than they enjoy actually helping people.

My first response is copied below with some additional points a further post will follow:

Patients are always a challenge in that they come in lots of 'varieties'. This is why we recognise the need for individualised, person-centred care. One variety is physical trauma laden to which the full-complement of the multidisciplinary team must respond. These patients and *their* crises bring out the best in us in terms of the skills and knowledge, team work they force us to exercise.

Among the plethora of other varieties there are those who are viewed as 'problems'. Like the Pepsi ad of decades ago they are variously and pejoratively described as -

multiattendin, attentionseekin, patiencesappin, bedblockin,
buzzabuzz-buzzin, heartsinkin, timewastin,
symptomfindin, carenumbin
.... patients!

If I receive referral information or heads up information on diagnosis of a 'tci' (to come in) that suggests the above is on the way, has arrived or worse "is on your caseload" - what do I do?

• Brace myself for impact?
• Go off sick (suffering loss of job satisfaction)?
• Become purely task or disease focussed, give up on effecting +ve change and improved outcome?
• Share collective anecdotes in the office - staff changing as a way to cope, de-stress, inject some humour?

OR do I -

• Avoid labelling them, or use these labels in a re-constructive way?
• Ask why are they 'who' they are?
• Gaze into their 'life history' and help them learn from it?
• Refuse to make gross assumptions, even based on previous experience with client - patient?
• Look at the individual wholistically - socially, educationally, behaviourally?
• Believe you can still make a difference (be the fly-half you can be and play ball)?
• Side step being tripped by foibles, behaviours and blatant displays of -ve obstructive ...... attitude that offend 'me'?
• Enter their space and do my utmost to find room for manoeuvre (this is the hardest test)?
• Speak to my manager(s) very tersely about protecting 'me' as a scarce resource and shout "OK where the hell is the gate keeper!"
• Or, as a nurse do you boldly go and seek out new strengths and new opportunities in the same way that Kirk, McCoy, Spock et al. (2264) go and seek New Life, New Civilizations...?

You may have an impossible lock to pick (in its most severe form this has become known as 'personality disorder'), but the nursing challenge is there in all its personal and professional glory. Address this personal - under-the-skin - slant - seek supervision. Be aware of the pit that some people fall into. The trap for some people with life chances they may have completely:

missed, never had, were stolen, denied,
took for granted, spurned,
totally - wasted.

Around the pit is the zone of judgement, but beware it is a singularity (no perspective) and very slippery.

• Otherwise go do your job: Nurse.

Nurse Philosophy list

Reference:

Kirk, McCoy, Spock et al. (2264) The Caring Imperative, To Boldly Go..., Four Quadrant Galactic Care Journal, Integrated Galactic Care Publishing Inc. itess-cube: 1701u-care4mesafelyandnicely

NT: Nurses urged to use checklists to reduce human error in practice

Last month Nursing Times included an item on checklists, highlighting work by the WHO in perioperative nursing and the 'Patient Safety First' campaign. Following surgery's lead is the realisation that similar checklists have the potential to improve communication and team working in other areas such as nutrition, situational awareness and pressure ulcer care.

Checklists are ubiquitous in our day-to-day lives, the dividend for using them is fairly obvious. What is less obvious is the fact that checklists alone are dead bureaucratic adornments. Checklists are animated by situations and thinking, reflective individuals in those situations. As Lomas reports there is a need to stop at an agreed key point in the patient pathway and ask the critical - checklist - questions. In team work this co-ordinated acknowledgement to complexity is essential for comprehensive, consistent and safe care.

What is interesting here is the emphasis on human factors. While checklists undoubtedly have a demonstrated - proven - role to play in safety, situational awareness is not a product of checklists alone. There is a need for learning and for the cultivation of cognitive lists. While human memory is fallibility incarnate - hence the role for checklists - there is also the need for skilled, knowledgeable professionals with the required communication and observational skills. The need for nurses to further develop observational skills has also been highlighted over recent months.

So as checklists are checked and logged: prepare a space for the mental checklist that is Hodges' model. The model is situated, person-centered and one of the original purposes was to help bridge the theory - practice gap. Try doing that with a checklist: alone

Clare Lomas, Safety checklists could cut 'human error' in clinical practice, Nursing Times, 106, 3, 26 January 2010, p.2.

Drupal musings 1: To Do List - Not To Do List

I have not written about my tinkerings with Drupal for a long time. Now I've new reading glasses with occupational lenses to boot I can hopefully make some proper headway.

The new PC is going to have to wait a while, so although the PC can and does run WAMP and Drupal I'm using a refurbished 15" Macbook Pro running MAMP to explore the budding functionality of Drupal 7.

As posted under Drupal on W2tQ ages ago I have taken the old html pages:

1. My introduction to Hodges' model (1998)
2. Brian's original course notes (I)
3. Brian's original course notes (II) Bridging theory and Practice

- with the aim of creating an archive within the new site. I'm re-visiting this job and have stripped the pages - naked: right down to the body and p tags. Eventually I will build some styling with CSS. I need a handle on the basic functionality to offer from day 1. The plan now is to push this (personal) envelope ever further without having a repeated scratch start. Drupal really does demand persistence. That's a problem when you can't give a project like this your ongoing attention.

A couple of additions I must organise include the constant companion that will be the Drupal notebook and a whiteboard. These will be useful over the coming weeks and months. The Drupal and PHP communities through a wide variety of sources are full of tips and code that you want to capture, filter and so possibly infuse into your project. I'm fast running out of excuses for the Drupal site no-show. On the positive side I have invested a great deal already attending the European Drupalcons in '08 and '09. Meeting a great group of Drupallers in Manchester and abroad. Reviewing my notes from Szeged + Paris and now with Copenhagen August 2010 in my sites (sorry!) - this means the project To-Do-List can get lengthy and threatens to overwhelm.

So, .... the Not-To-Do-List is even more important!

Many more Drupal musings - to follow ...

Topicscape Care Domain links in 3D - for the PC

Following the post on Sunday, January 24, 2010 I have tried Topicscape and the 3D rendition of my links pages which is for the PC only. Unfortunately, for me the experience is very slow as my 7 year, 2 month old Pentium 4 2.6Ghz with its equally aged graphics card is really not up to the task. If you have a recent PC with a suitably endowed graphics card*, perhaps you will see what I sadly - for the time being - am missing.


Thanks again to Roy Grubb for recognising the organisation and effort behind the four links pages I have compiled from 1998 to date. There's a great irony in my viewing the links as a 'monster', then here they are rendered by GPU's that more commonly play host to a variety of game monsters. Recently people# have let me know of their surprise and pleasure to see that there is still a role for a human hand (and reflective mind) to weave something beyond raw Google. Of course the developments in the semantic web and RDF ... can take this even further.

Additional links:

Hodges' model links in 3D with Topicscape

*I plan to correct this in the near future with a new PC sporting a CUDA capable graphics card - also for SETI @ Home et al.

#Dear Peter

Many thanks for this, I look forward to reading the material and learning more on what seems to be an interesting model.
I’ve added a link on our site to yours – the wealth of links available on your site is phenomenal!

Many thanks and kind regards

Charley
---------
Charley Baker
Madness & Literature Network
Research Associate
Fellow of the Institute of Mental Health
University of Nottingham
School of Nursing, Midwifery and Physiotherapy
Education Centre,
London Road Community Hospital,
Derby, DE1 2QY

Notes (II) for a 2010 introduction to the Health Career Model

... Where to start?

By its very nature as already suggested Hodges' model is difficult to explain. There are so many elements that demand our attention and so many avenues to run. Despite revealing one heading to be followed, Murphy (2002) describes how a theory of concepts is still elusive. From this we might focus purely on nursing and take a professional stance. We should be able after all to assume solid grounds for the system that supports nursing: namely nurse education. There is no need to do this as existing theories of concepts can provide a vehicle for explanation and research of Hodges' model.

Frequently acknowledged as a science AND an art, the individual-group axis in Hodges' model and the accent on communication makes individual and group psychology as much a pivotal source of knowledge as human anatomy and physiology. There are differences in the methods of verification, but the dependency is there and evident in the core nursing curriculum. Even though psychology remains a young science, resort to psychology is advantageous in other respects as the development of cognitive science and computer science can also inform our thought and research on Hodges' model. Fundamental to this is the basic form of the model construct the 2 x 2 matrix.

There are a great multitude of models that take this 2 x 2 matrix form. Apart from mathematics examples one the most commonly cited and influential is the so-called Johari window model of Harry Ingham and Joseph Luft which dates from 1955. Luft and Ingham were psychologists who created their model at the University of California, Los Angeles, while researching group dynamics. The Johari model has found a home in soft systems problems and can now be found in many other variations and one-off examples. There are whole books devoted to the subject of '2 x 2', an acknowledgment indeed of their utility and ubiquity (Lowy and Hood, 2004). From the OHP transparencies of old to the latest data projection forms, the 2 x 2 matrix is the tool of choice in the management consultant's armamentarium. This special cognitive device can also serve the local and global health and social care community.

Ref:
http://www.amazon.com/Power-Matrix-Thinking-Decisions-Management/dp/0787972924

The Power of the 2 x 2 Matrix - at Wiley

Additional links:

http://hodges-model.blogspot.com/2008/02/big-book-of-concepts.html
[ Murphy, G. L. (2002). The big book of concepts. Cambridge, MA: MIT Press. ]

http://hodges-model.blogspot.com/2010/02/notes-for-2010-introduction-to-health.html

Online journal Audiovisual Thinking

On January 7th, the online journal Audiovisual Thinking was launched on www.audiovisualthinking.org, at the same time opening for the first round of submissions from researchers all over the world. The journal is created by an international group of young researchers and will be the first of its kind, the worlds first journal for reviewed, academic, **audiovisual** contributions.

The idea is that research can be disseminated and debated with visuals and audio as the primary carrier of the content, instead of written or spoken text. The call is not for documentaries nor popular science videos. The call is open until the end of March, so please check it out. If you have comments, questions or want to discuss a contribution, please let me, Thommy Eriksson at the IT University (GU, Chalmers) know - e-mail thommy at ituniv.se ! If you know someone which might be interested, please spread the word.

More information at: www.audiovisualthinking.org

Best,
Thommy Eriksson
Ph D student Thommy Eriksson
Chalmers University of Technology

My source: Jill Anderson, MHHE at JISCMAIL.AC.UK

Notes (I) for a 2010 introduction to the Health Career Model

.... The structure and composition of Hodges' model can be viewed as a sketch, a back-of-the-envelope idea expressed as a diagram as per (insert figure 1 and 2) and in combination (figure 3). While this is a perfectly valid interpretation it invites the view that Hodges' model is simplistic. In its basic unpopulated form the model is simplistic, in the same way that a blank canvas, computing device display, or piece of paper is simplistic. There is however, much more going on here, consideration of which can lead us to new ways to justify and explain the model.

"Make everything as simple as possible, but not simpler"
Albert Einstein

Einstein is helpful because while simple - the model provides the foundation for global conceptual scope (complexity) should this be needed. Hodges' model demonstrates the complexity of health and social care without making it simpler.

"Simplicity means the achievement of maximum effect with minimum means."
Dr. Koichi Kawana, Architect

If Hodges' model is simple, a way to represent the tip of the health and social care iceberg, then why should we then wish for global conceptual scope? The reasons are manifold, but revolve around one factor:

safety.

...

Quotes source: http://www.petefreitag.com/item/496.cfm

RCN UK 2010 General Election 6 priorities - framed in Hodges' model

Previously [Please sign up: NURSING COUNTS ]

The RCN's 6 priorities hit the POLITICAL sweet-spot. In the table below I have related each of the priorities to a care domain of Hodges' model with a rationale that follows:

Give nurses time to train	Protect the Nation's health
Improve care for those with long term conditions	Standing up for staff who speak out Safer staffing levels Sustain health care investment

Timeout from the clinical arena for training is always a political issue. It is also at the behest of the individual. This includes individual practitioners and their managers.

The public's health (and mental health) is of course grounded in the group, but is initially framed by evidence, knowledge and preventive medicine.

Long term conditions may impact the quality of life of the individual concerned, but the effect on carers and the social ripples are also profound.

The Demand - Supply equation in health care may be reduced to raw, mechanical numbers, but they quickly become the political football of investment statistics.

So many false economies in stretching the more expensive resources when it comes to staff AND patient (carer) safety. Skill mix and staffing levels are vital for job satisfaction, service development, quality and safe outcomes.

Motivation and intent may be concepts exercised by individuals, but the political environment must support nurses who speak out for high standards of care, safety, the public good.

HoNOS, checklists and semi-structured interviews

Mental health services not routinely (and formally) using HoNOS (Health of the Nation Outcome Scales) are gearing up with a push to implement the scale across services by April. HoNOS has been around for a long time almost 20 years so it is time it earned its keep. Perhaps high quality tools take time to emerge from the noise and chatter of the care marketplace? ;-)

Although they are available, I've been putting a presentation together to help get to grips with HoNOS in the role of a trainer. The evidence for the validity and benefits of using HoNOS is well established, with the HoNOS family of scales boasting global usage and development:

• HoNOS for working age adults
• HoNOS65+ for older people
• HoNOSCA for children and adolescents
• HoNOS-Secure for use in health and social care settings secure psychiatric, prison health care and related forensic services, including those based in the community)
• HoNOS-LD for learning disabilities
• HoNOS-ABI for acquired brain injury (ref.)

The number of assessment, intervention and evaluation tools available to clinicians AND managers begs the question (ironically): is there 'space' in the toolkit for yet another tool? If HoNOS can help establish a coherent currency for mental health commissioning beyond the block contract then this is most welcome. Mental health services need to move forward on several fronts. There is a timeline running with completion of this difficult task in its sights.

One set of guidance for HoNOS points out that:

The scales are not used as a checklist or semi-structured interview, but form a brief record of severity.

There is some succor there then, since Hodges' model is a checklist and a quad-structured interview there is still a role for a global conceptual framework.

There's nothing like a full and tidy set of tools!

Honos health of the nation outcome scales report on research and development July 1993 - December 1995

Sir Terry Pratchett: 34th Richard Dimbleby Lecture - Shaking Hands with Death

I watched Sir Terry Pratchett's Richard Dimbleby Lecture (I am not yet sure if this will be available on iPlayer?). The issues are already well recognised, much debated and provide a constant tap on the shoulder for us all:

Although the poll numbers are small
there is a definite shift afoot.

From the BBC:
One of the world's most popular authors gives the 34th Richard Dimbleby Lecture from the Royal College of Physicians in London.
Sir Terry Pratchett announced in 2007 that he had been diagnosed with a rare form of early-onset Alzheimer's disease. In his keynote lecture, Shaking Hands with Death, he explores how modern society, confronted with an increasingly older population, many of whom will suffer from incurable illnesses, needs to redefine how it deals with death.
The acclaimed creator of the bestselling Discworld series, he is the first novelist to give the Richard Dimbleby Lecture. His books have sold more than 65 million copies and have been translated into 37 languages.

I realised in listening to Sir Terry that although I usually apply socio-technical in an informatics context, the term is of course equally applicable to the debate surrounding assisted suicide, or assisted death as Sir Terry prefers to call it. The quality of (our social) life is lost in the beep, buzz, hum and scan of hyper-technical health care.
It is as if the technology of health care is producing relativistic effects. Instead of the travellers being explorers heading for stars at near the speed of light; they are travellers cast adrift within a long term chronic disease that cuts them off from time, place, person, those they love and - for Sir Terry - choice. ...
This debate will run on ...
Photo source: The Guardian