Autonomy Cube(d)

OBSERVATION
|
INTERPERSONAL : SCIENCES
OBSERVATION  ---------------------------------------  OBSERVATION
SOCIOLOGY : POLITICAL
|
OBSERVATION

	Rosa Menkman from amsterdam, Netherlands, CC BY 2.0 <https://creativecommons.org/licenses/by/2.0>, via Wikimedia Commons

"When installed in a gallery, the cube creates an open Wifi hotspot that uses the alternative Tor network to anonymise internet use."
Jobey, L., (2016)  Trevor Paglen What Lies Beneath, FT Magazine, 2-3 January. p.20.

Trevor Paglen: Autonomy Cube (2014)

Whitechapel Gallery, London, January 29 to May 15.

Photo source: e-flux - Edith-Russ-Haus for Media Art

                             Autonomy-Advocacy Cubed?
     Late 1970s                      1980s-1990s                         2000s...
   Nurse Advocate                 Nurse as Advocate?             Independent Advocacy
                           
             Ongoing nurse advocacy role amid the politics of healthcare...

Attending: Active listening c/o Baggini & TPM

Reading through more past issues of The Philosopher's Magazine, I came across Baggini's short contribution of Attending one of "50 New Ideas".

That Hodges' model has a role in attention must follow from its main purpose as an aide-mémoire. To 'know', to recognise that your memory has been jogged is surely to attend.

I realise that Hodges' model represents a philosophical smörgåsbord, rather like the 50 ideas in this issue.^

Baggini draws on a film for inspiration on empathy, feelings for other, humanity and moral philosophy. For Hodges' model our context can encompass media, but the focus remains empathy, ability to relate in the clinical, social care context. Attention and interpersonal skills come the fore here.

If you are not hungry, the model (smörgåsbord) can be considered as empty. This is a precondition for 'attending' - having unconditional positive regard. Apart from information that relates to the patient's, student's, and your safety the domains of Hodges' model are vacant spaces. How they are populated depends on how we attend. There are important lessons for students here. The first is their phone. Its being on their person, may impact their ability to attend to the other (person). The window to outside isn't a screen either.

 Individual
  |

     INTERPERSONAL    :     SCIENCES               

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

SOCIOLOGY  :   POLITICAL 

|

GROUP

previous experience cognitive furniture - elephants in the room (for all?) attend/attending attention active listening authenticity observation empathy - rapport therapeutic relationship unconditional +ve regard I see, I hear you ...	physical space physical environment measurements furniture - layout position / posture observation

Attending needs to be active listening. This includes all the senses, although sniffing the air is probably  best avoided - body odour may announce itself. Attention, then is synonymous with observation and in this context must span an individual's physical and their psychological presentation. You may draw social, political and spiritual assumptions, it is human to do so. Intuition has a role in healthcare but initial conclusions must be recognised as potentially premature and be verified. 

To initiate, be-in, partake-in such situations is to attend to the verbal, and non-communication; the data you already have and information communicated, including in a referral. Is this confirmed, challenged, what is your opinion? What about your colleagues? Most importantly, what does the person (patient, client... say)? What is unspoken? Do you understand? Did you seek clarification? 'Where' have you been / not been in Hodges' model? What picture is emerging at this stage?

It is gratifying that this is the first of the 50 'new' (2016) ideas in TPM #72. 

More to follow - drawing on TPM and (I think, Hodges' model as a 'philosophy? Surely not!)

Baggini, J., Attending, The Philosopher's Magazine, 1st Quarter 2016. Issue 72. pp.21-22.

TPM #72 cover image: https://ericthomasweber.org/correcting-political-correctness/

Fallacies of Work as Imagined: c/o Steven Shorrock - HSJ Patient Safety

I came across the following image on twitter. The tweet is also copied below.

This post is prompted by one from 'The Varieties of Human Work' on the Humanistic Systems blog 05/12/16 by Steven Shorrock. The focus is understanding and improving work, and in his opening there is a sense of very large net having to be deployed to capture all the disciplines and dimensions that are invariably involved in work.

"One of these is the simple observation that how people think that work is done and how work is actually done are two different things. This observation is very old, decades old in human factors and ergonomics, where it dates back to the 1950s in French ergonomics (le travail prescrit et le travail réalisé; Ombredanne & Faverge, 1955) and arguably the 1940s in analysis of aircraft accidents in terms of cockpit design (imagination vs operation). Early ergonomists realised that the analysis of work could not be limited to work as prescribed in procedures etc (le travail prescrit), nor to the observation of work actually done (le travail réalisé). Both have to be considered. But these are not the only varieties of work. Four basic varieties can be considered: work-as-imagined; work-as-prescribed; work-as-disclosed; and work-as-done. These are illustrated in the figure below, which shows that the varieties of human work do usually overlap, but not completely, leaving areas of commonality, and areas of difference."

The varieties of human work.

It immediately struck me how well the diagram can be translated and transposed on to Hodges' model on several levels and as per Steven Shorrock's excellent post. I acknowledge I am playing with language, but initial thoughts included:

1. As per Shorrock: the difference between how people think about work and how work is actually done.
2. Shorrock explains how for example 'work-as-imagined' draws on the other forms of work.The level of overlap in between the forms of 'work-as-' is as diverse as the contexts that arise and constantly change.
3. There are many 'gaps' identified in Steven's post [not in the sense of a fault with his post]. A subset of these may relate to the theory-practice gap which was one original purpose of Hodges' model, to help close this gap.
4. Orders of scale: from a single action to a whole job and its specification.
5. The way the 4Ps process, policy, purpose and practice can be used (I identified the 4Ps within Hodges' model, one per care domain, many years ago).

As has been pointed out to me (on twitter) the context here is 'work' and not healthcare, but as Steven notes there are many disciplines, with commonalities and differences. I am really grateful to Steven for his post, in which he also stresses the overlap. 'Work-as' is a flux. Hodges' model can be viewed through time as series of frames. Below are some rather unstructured notes [musings] relating and extending the context of Shorrock's image and post to Hodges' model:

individual - self

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group- population

'Work-as-Imagined': Of the four P's I have placed 'PURPOSE' here, since the individual's purpose must (ideally) achieve synergy with colleagues and the organisational objectives and goals. 'Work-as-Imagined' involves thought (and so is infinite in variety) whether use of imagination is day-dreaming, or radically innovative. Until AI does take over, this is the 'meta' - cognitive domain. Amid many, Shorrock makes an important point in how we imagine the work other disciplines do. Often so many stereotypes follow that are often revealed in referrals and expectations. Shorrock highlights this at the macro level of policy makers [lower right in #h2cm] having to imagine the operational aspects of work; and the simplified accounts of surgery for a patient by anaesthetist and surgeon (while meeting the requirements of informed consent). This domain may be 'work-preserving' in humanistic terms as it is the realm of tacit knowledge, creativity and innovation. Although the artifacts of simulation are ultimately produced in the SCIENCES domain, they are 'imagined' in case studies and scenarios. Shorrock helps make it clear how much of work is theorised and practised virtually, but with recourse to imagination not technology. Mental illness and the systemic - organisational response is mediated diametrically in Hodges' model. Ongoing critique of psychiatry and mental health services in some quarters appears to suggest that being unable to work-as-imagined here, means loss of self and identity that is then outsourced and effected by proxies and advocates. [Discuss?]	'Work-as-Prescribed': Reading 'prescribed' literally then drugs and other physical treatments arise here in the SCIENCES domain. The 4'P is PROCESS suggestive of procedures, specifications, instructions and formal rules. Process is important allied with PURPOSE in that if (your) can be described formally, by a set of rules then you may be vulnerable to your job being taken by a robot through 'robotic process automation'. When I started in the NHS in the 1970s there was a shift taking place from being task-oriented (mechanistic) to individual/patient-centred (humanistic). Shorrock notes how there are relatively fewer examples of work-as-prescribed. Developed nations are waiting to see how many existing jobs are lost to AI and robots, but how many new ones emerge. (Can the developing nations 'skip' several prescriptions?) Here, we also apply time to work. The past, current work and the future. Will we still work the same hours? Is there a lesson in '0' hour contracts? An obvious aspect of work is day vs. night shifts. 'Work-as-Prescribed' also reinforces the presence and context of the SOCIOLOGICAL domain. Now, conferences are devoted to 'social prescribing'. By its nature this is more often than not 'public' and therefore 'disclosed'. Citizen science and patient involvement provide a further angle on work-as-prescribed. As does what is prescribed (especially in what is used) must to some degree influence what is proscribed in what is not used.
'Work-as-Disclosed' Sharrock writes concerns how work is explained and communicated. This will also involve teaching formally and health professional to patient, carer and public.  The challenge is that thinking about work and actually doing work is a SOCIO-POLITICAL act - transaction (as the literature demonstrates). Socially, whether or not someone is working is also disclosed in their domestic  comings and going to work. The socio-political dimension is evident in the assumptions that follow homeless peopleand their apparent 'staying' (many do work?)? There are those who opt not to disclose at all and live off-the-net. SOCIO-ECONOMICALLY there are constant references to 'pay-gaps' especially by those groups and their representatives most affected by low pay and austerity. While the social care workforce toil in the community, social care funding, provision and integration is pushed into the long grass that is green papers. Despite the social value and importance of this work, the status of this sector is signalled - disclosed as poor. Nurses globally are campaigning to establish in law the requirement for safe-staffing levels. Sharrock alludes to the challenge of nursing as PRACTISED on the 'shop-floor' and ongoing studies on staffing - establishments and skill-mix. In the 1980-90s expert systems specialists interviewed workers  in an attempt to understand the knowledge acquisition and elicitation associated were their profession - community of practice. These humanistic care (knowledge) domains reflect the qualitative approach to research. Work-as-disclosed also communicates to would-be future recruits. How are the aspirations of teenagers and mature entrants first experienced, discussed and carried forward socially?	'Work-as-Done' simultaneously speaks of power, employment, accountability and regulation.  As four conceptual spaces #h2cm indicates the 'distance' between concepts that shifts according to context. The space that work takes place within and how people are managed, organised, controlled for efficiency with reminders, queues, appointments, and waiting areas are signs of the institution. The person was a long way from the creators of the Victorian asylum, even as they sought to establish (stamp?) a 'standard' level of care. What difference does it make when work-as-done is bound to an individual and collective sense of duty? The counterpoint is precisely [mechanistic] work-as-done. Work-as in shift completed and recorded - clocked as such. Work-as-done: the 12 hour shift or as already mentioned work-as-NOT-done due to the flexibility afforded by zero hour contracts. Work-as-done also denotes [scientifically] the concepts of power, energy and effort. So, work-as-done must result in personnel actually feeling 'done': burnt-out when safe-staffing is not assured. The old saying: "If it is not documented it was not done.", springs to mind. Shorrock refers to surgery and loss of life. What was 'done' and what does an inquiry reveal? What is actually done and the way it is done if varies - contravenes 'norms' rules then there is a issue of whistle blowing. The question then becomes was the work done as it should - must - be? The 4P in this domain is POLICY.  Perhaps a box-tick here also accounts for 'work-as-' elsewhere?

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

— Iain Moppett (@IainMoppett) July 3, 2019

Anticipatory Prescribing as part of Anticipatory Care

This post is derived from a selection of the main concepts found within three papers (references listed below) on 'anticipatory prescribing'. Some explanation may assist. I have duplicated 1. What is current practice? across the domains to suggest that the question needs to be answered for each of the care (knowledge) domains. The same principle applies to the repetition of the attitudinal questions at the individual and group (sociological) level. Person-centredness demands that the patient's views are paramount plus the aggregated responses of the group as a whole.

Perhaps there is a 'drug TIME' too, which operates across all the domains once more, and each variously weighted objectively and subjectively? The concept of control and assessment of control is also critical.

I've placed GP decision-making across both 'individual' domains described as it is as a 'process' and for the patient as 'bedside manner', as also reflected in the GP and healthcare professional's communication with the family.

Clinical effectiveness and observations are likewise span the interpersonal and sciences domains. This is to denote the need to achieve and sustain parity of esteem and integrate physical and mental health care - pastoral and spiritual also.

'Cost' is anchored in the political domain, but clearly there are much wider economic ramifications, both in quality of life, quality of death and the way 'cost' is determined, measured, analysed, evaluated and reported.

For me nursing, medicine, healthcare are most effective when they are anticipatory. Observation, reflection and critical thinking are key. In a way for an individual to be health literate is a preparation for self-care. Although clearly in a general sense of health and well-being; not necessarily being literate with respect to a long-term medical condition.

Hodges' model is an idealisation and the detail is obviously described in the papers listed. The intention below is for readers to gain an appreciation of anticipatory prescribing and the application and scope of Hodges' model.

 Taking a larger perspective anticipatory prescribing is part of anticipatory care.

@GeriSoc https://twitter.com/GeriSoc/status/1374716732120645632?s=20

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

Anticipatory Prescribing Reassurance for patient, family &  friends clinical effectiveness subjective TIME observation agitation, distress (mood, anxiety, orientation, communication, identity - self, fear, understanding, mental capacity...) The patient's spiritual well-being needs are met*. 1. What is current practice? 2. What are the attitudes of patients? 3. What are the attitudes of family carers? 4. What are the attitudes of community healthcare professionals? [as individuals] GPs’ discussion with patients (Advanced care planning - choices) 5. What is its impact on patient comfort and symptom control?

Anticipatory Prescribing Physical access to medication and treatment is assured. clinical effectiveness objective TIME observation remote anticipatory prescribing increased 24 hours availability (out-of-hours) The intervention seeks to improve [my] symptom control pain, nausea and vomiting, agitation, and respiratory secretions. The Covid-19 pandemic has accelerated the practice of Anticipatory Prescribing; more terminally ill patients are having end-of-life care at home and in care homes. 1. What is current practice? New routes of administration injection, oral, sublingual, or rectal 5. What is its impact on patient comfort and symptom control? GPs’ decision-making processes Research: Systematic review and narrative synthesis Semi-structured interviews Web-based survey

An important intervention in supporting patients and families who wish to have last days of life care at home. 1. What is current practice? 2. What are the attitudes of patients? 3. What are the attitudes of family carers? 4. What are the attitudes of community healthcare professionals? [collectively] 5. What is its impact on patient comfort and symptom control? Patient and families’ well-being throughout the end-of-life journey *There is concord and respect regards patient's spiritual well-being needs. GPs’ discussion with family family caregiver administration

The Independent Review of the Liverpool Care Pathway found that the use of Anticipatory Prescribing without adequate explanation or justification led to families being concerned about over-sedation and the medication hastening death. 1. What is current practice? 5. What is its impact on patient comfort and symptom control? 6. Is it cost-effective? Revise pharmaceutical regulations to permit repurposing of anticipatory prescribing medications in care homes, wider community drug access, and recycling unused medications returned to pharmacies. Address stock shortages.

Bowers B, Ryan R, Kuhn I, Barclay S (2019) Anticipatory prescribing of injectable medications for adults at the end of life in the community: A systematic literature review and narrative synthesis. Palliative Medicine 33(2): 160-177 https://doi.org/10.1177/0269216318815796

Antunes B, Bowers B, Winterburn I, Kelly MP, Brodrick R, Pollock K, Majumder M, Spathis A, Lawrie I, George R, Ryan R, Barclay S. (2020) Anticipatory prescribing in community end-of-life care in the UK and Ireland during the COVID-19 pandemic: online survey. BMJ Supportive & Palliative Care; http://dx.doi.org/10.1136/bmjspcare-2020-002394

Bowers B, Barclay SS, Pollock K, Barclay S (2020) General Practitioners’ decisions about prescribing end-of-life anticipatory medications: a qualitative study. British Journal of General Practice; 70(699) e731-739 https://doi.org/10.3399/bjgp20X712625 

 

Nature, Arts + Sciences: Dear Nancy and Tim ...

 individual 

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

Soft sciences [Soft] observation Arts, creativity Innovation Wild mental 'grounding' Mary  ::   Tim	HARD sciences [Hard] Observation Students need a mixture of Art and Science A levels A Natural History GCSE Taking young people outdoors Forest school
Colwell :: Smit Arts Nature literate society	Curricula The human-ities in Politics?

 

My sources:

Woolcock, N. (2020) Pupils should mix arts and science, says woman leading top universities, The Times, 24 October, p.6.

Today, BBC Radio 4, 16 November, 2020, 0845-0851 Available for 25 days)

New patient chart to save 6,000 lives a year in the UK

The purpose of NEWS - National Early Warning Score is to standardise the assessment of acute-illness severity in the NHS and in doing so: save lives.

For me in the late 70s early 80s there was great emphasis placed on doing the charts, on 'obs' and the art and skill of observation. As a student nurse, you were finally nursing. From my mental health base, I've noticed new students today retain this enthusiasm to do the TPR and BP. To sign-off this essential competency. I mentioned art and skill above to highlight the intuitive side, not to diminish the underlying knowledge. Recognition is essential to prompt action, critical in acute-illness.

I notice some comments in response to NEWS express concern about finding agreements on units and how standards might stifle innovation. Against this though, Nursing Times reported an acute problem with the quality of nursing observation skills in 2009.

It goes without saying that the elements in NEWS are physical: respiratory rate, blood oxygen level, temperature, blood pressure, heart rate and level of consciousness. It will be fascinating to follow the results and not just in England.

In terms of integrated and holistic care - other measures will be needed.

My source: The Independent (27 July 2012).
Laurence, J. (2012, July 27). New patient chart to save 6,000 lives a year in the UK, The Independent. p.12

Book Review: v Mathematics and Art: A Cultural History

Mathematics + Art

Running since May, I need to wrap this review up. As already noted this is a marvellous read and not just as a supportive friend through lockdown. Conscious of more reading and a new part-time clinical role, I could write so much more and read so much more into the text.

 Gestalt and patterns are described and illustrated, which prompt me to 'see' fields of knowledge, care domains and blank/blanc space (p.263). Amid this physical and psychological data can assume their simplest forms? Piaget is significant too in the thought on whole-part distinction and our preoccupation (science's) with a unified world view. This fits with future reading on Hodges' model and how learners categorize and develop their disciplinary and professional vocabularies.

If the mathematics might deter further reading on group theory, perhaps symmetry in art and sociology might be persuasive (chap. 7)? Does chapter 8, 'Utopian Visions after World War I mean that introspection and with it reflection are futile (p.288)? There could be another model/theory of nursing here: with Psi waves, Bohr Kierkegaard (p.281 Either-Or 1843), ideas, observation and competition in physics interpreting physics the uncertain times continue. I do get a (vague?) sense that the notion of consistency is very important and of use here too (p.322). As in healthcare and science the search for evidence is relentless, it is sobering to read (again) of the limits of language and hence mathematics (p.326, Wittgenstein's tower of meaning, Figure 9.3). The book is multicultural yet reminded me of the feats of navigation, observation and collective memory across Oceania.

In my notes, I picked out Karl Gerstner's, Aperspective 1: The Endless Spiral of a Right Angle and looking for an image to post here found an Aeon post:

How physics and maths helped create modernist painting

If you visit the post above the relevance of Aperspective 1 to me is not necessarily obvious, yet Hodges' model is full of axes, right-angles, symmetries and asymmetries. Recently, working through a little angst, I've been writing about Hodges' model from a definitive perspective. If there was a manual what would it 'say'? The center of the model is a fusion of right angles and disciplinary domains. What is involved, implied, communicated in the many forms of crossings (p.386)?

A.R. Penck: 'The Crossing' (1963)

Michel Serres is quoted:

"The ordered structure blew up." p.410.

With a long-standing interest in visualisation in the humanities, I had written Levi Strauss - maths in social sciences in my notes.

Bourbaki, Sontag the names come thick-and-fast - more reading.

This is an amazing book, the content, quality, index, references. I'm going to close here, but may return in future (there's 556 pages and the end notes are excellent too). As I pick up another book, a great find is another disciplinary bridge (Fechner, Psychophysics, 1860) more recently rediscovered in Buddhism and neuroscience?

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group - population

Psycho-	-Physics

The Crossing image: 

https://www.dw.com/en/exhibition-utopia-and-demise-shows-tensions-in-east-german-art/a-50303887

Lynn Gamwell (2016) Mathematics and Art: A Cultural History. Princeton, New Jersey: Princeton University Press. ISBN: 9780691165288. p.283.

(Sincere thanks to PUP and John Wiley for the review copy.)

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

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

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

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

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

'Anafranil Film

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

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

I wonder if the film is archived somewhere?

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

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

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

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

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

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

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

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

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

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

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

Dear Rachel (Ms Magee)

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

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

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

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

An·a·gram: 'secure' = 'rescue' .....

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

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

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

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

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

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

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

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

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

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

Best,
Peter

Book for review: v "Philosophy of Care - New Approaches to Vulnerability, Otherness and Therapy"

I think this is the final post for Philosophy of Care (think! There is so much more ...). There are other chapters more salient to me personally, but for Hodges' model and the collective human enterprise, I think chapter 5 by Virginia Held is the most important. There's not just a chapter, but three in Part II 'Care and Economy'. I appreciate the reminder of Kate Raworth's Doughnut Economics which challenges;"the dominant assumption of the economy as a machine". I notice on Twi/X Kate Rowarth reflects on the UK's election:

The book 'Doughnut Economics' opens with the story of Yuan Yang who, as a young economics student back in 2008, was challenging the outdated theory she was being taught. Last night she was elected as the first-ever MP for Earley & Woodley. Huge congratulations @YuanfenYang!

    https://x.com/KateRaworth/status/1809216007518507248

I gave Keir Starmer a copy of Doughnut Economics just 10 days before he became Labour Party Leader. So will the book make it onto his bookshelves in Number 10? More importantly: will policies for a regenerative & distributive UK become real under this government?...

     https://x.com/KateRaworth/status/1809235013403136029

While in Philosophy of Care, another three words stood out:

"'Big-picture thinkers'^, Raworth notes, have offered alternative visions, but they have been dismissed by the field of economics." p.102.

continued ... 

'Thinking outside the box: alternatives to standard inpatient mental health care' by Amber Jarvis

c/o The Mental Elf on 'X' I came across a blog post by Amber Jarvis:

Thinking outside the box: alternatives to standard inpatient mental health care

Amber's post considers a study by:

Griffiths, J. L., Baldwin, H., Vasikaran, J., Jarvis, R., Pillutla, R., Saunders, K. R., … & Johnson, S. (2025). Alternative approaches to standard inpatient mental health care: development of a typology of service models. International Journal of Mental Health Systems, 19(1), 1-13: https://pubmed.ncbi.nlm.nih.gov/40247283/

At an online meeting this evening, near the close the discussion loosened and alighted on AI. The ability of AI to summarise a large text file, a *.pdf and create discrete web HTML pages. The racial bias 'built-in' by human coders, reflected in outputs; that point to structural racism. 

Finding this paper on X, boxes are the bread and butter of Hodges' model. Not just thinking outside a box, or inside one, but several and with a final twist - to follow. Amber begins:

'Inpatient mental health care involves staying in a hospital or specialised facility to receive intensive, round-the-clock support for serious mental health needs (Staniszewska et al., 2019). Whereas acute inpatient services typically respond to immediate crises, longer-term wards support individuals with more complex needs and a higher level of ongoing risk.

Inpatient services are a core component of our mental health system — whether someone stays for a night, weeks, or even several years. However, inpatient care has recently come under growing scrutiny – and for good reason.'

A Community Mental Health Nurse since 1985, my in-patient experience is a tad misty, but not misty-eyed. As the wards: psychogeriatrics, long-stay, female acute admission were simultaneously challenging, rewarding - in the sense of being able to make a positive difference, changing what were institutionalised practices, no personal clothes, lockers, tea urn, no banking, few visitors (admission wards excepted). It was all very quotidian: check the bath book. Then tell, confirm, assure the patient, 'yes!'. It is your bath day. I've posted previously about critical mental health. You do (should?) quickly learn you are part of a system, a machine; and the distinction between person- patient-centred and service-centred care. The need to do my 'general' quickly emerged too. 

As ever, two words, across Amber's post and Griffith et al's title, stand out; 'map' and 'typology'. I must revisit and post about:

Macduff C. (2007). Typologies in nursing: a review of the literature. Nurse researcher, 14(2), 40–50. https://doi.org/10.7748/nr2007.01.14.2.40.c6020

Part-time work since 2020, in two adult CMHTs and a recovery team, has provided an update. The first as COVID emerged, was a bit of a shock in terms of diagnoses, caseness, the proximity to the law and forensic psychiatry, thresholds for referral, changes to mental health law (that were now more practical) and the management of patient's finances. 

So, to return to last night's brief online discussion, the observation of how racism is ongoing, brought up the fact of racism being structural and institutional (Dean & Thorpe, 2022). The change needed is an intergenerational break, which doesn't bear thinking about. The National HEALTH Service faces the same challenges in the shift to prevention, and addressing racism. Where is the workforce, going to come from, to help recovery, health and related literacies (media, emotional, financial)?

It is easy in boxes like Hodges' model (and others) to be idealistic. Ideally as I learned of Community Psychiatric Nurses being recruited, six of us, we all should have asked:

What is the plan?

What is the model of care?

What characterises 'care in the community'?

How do we prevent relapse, readmission?

Is there a 'halfway house'*?

We did, to an extent. There was great enthusiasm, motivation, idealism, co-ordination, collaboration  (Tyrer & Gelder, 1990) and leadership. 'We' had an association,^ and a journal. Back then the Royal College of Psychiatry produced a report on CPNs. Is there a message in this? Progress was and has been made, but the promise has not been delivered. With care in the community having regressed, an incomplete 'project'.

I will read more and revise this post, or more likely add another: with less 'history' ...

Individual

|

      INTERPERSONAL    :     SCIENCES               

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

 SOCIOLOGY  :    POLITICAL 

|

Group

Model of Care	Model of care
Model of Care Care in Community Children - Schools - Education	Model of care 'Care Leavers'

*'Cross-settings' in Griffith et al.

^https://www.unitetheunion.org/what-we-do/unite-in-your-sector/health-sector/mental-health-nurses-association

Lorraine T Dean, Roland J Thorpe, What Structural Racism Is (or Is Not) and How to Measure It: Clarity for Public Health and Medical Researchers, American Journal of Epidemiology, Volume 191, Issue 9, September 2022, Pages 1521–1526, https://doi.org/10.1093/aje/kwac112

Tyrer P, Gelder M. The future of community psychiatric nursing: some research findings. Psychiatric Bulletin. 1990;14(9):550-551. doi:10.1192/pb.14.9.550

ii 'Thinking outside the box ...'

iii 'Thinking outside the box ...'

See also: 'institution' : 'racism' : 'typology' : 'map' : 'Forensic'

Nursing: magnetic Force 5

Back in 2009 I came across a post - Nurse magnets crucial for recruitment and retention about the 14 Forces of Magnetism:

In 1983, the American Academy of Nursing conducted a survey of 163 hospitals to learn why some hospitals attracted and retained well-qualified nurses who were devoted to quality patient care.

The 14 Forces are listed and described by the ANCC. The forces themselves include:

• Force 1 Quality of Nursing Leadership
• Force 2 Organizational Structure
• Force 3 Management Style
• Force 4 Personnel Policies and Programs
• Force 5 Professional Models of Care
• Force 6 Quality of Care
• Force 7 Quality Improvement
• Force 8 Consultation and Resources
• Force 9 Autonomy
• Force 10 Community and the Hospital
• Force 11 Nurses as Teachers
• Force 12 Image of Nursing
• Force 13 Interdisciplinary Relationships
• Force 14 Professional Development

The professional, organizational, and political (policy) emphasis of the 14 forces is obvious and becomes clear when each is weighed in terms of where it sits within the domains of h2cm.

Try it as an exercise. ...

Recruitment is ALL about magnetism.

If you are unsure, ask a magnet about the meaning of retention.

Demographics are already applying pressure upon these forces of magnetism. Not just when referred to explicitly in the USA within organizational media; but globally. Demographics is another magnet - it approaches with increasing force.

From here in the UK (and readers elsewhere) we have to exercise care when models are mentioned. While the theorists and philosopher's of nursing nail their definitions to the mast (h2cm?) there remains a models muddle, not just in the variety of models of care, but in the levels at which they operate. This is not a criticism, it's an observation - consider Force 5:

Force 5: Professional Models of Care
There are models of care that give nurses the responsibility and authority for the provision of direct patient care. Nurses are accountable for their own practice as well as the coordination of care. The models of care (i.e., primary nursing, case management, family-centered, district, and holistic) provide for the continuity of care across the continuum. The models take into consideration patients’ unique needs and provide skilled nurses and adequate resources to accomplish desired outcomes.

In the US in particular 'models of care' (moc) often refer to finance and accountability of costs (the market process), in the UK moc might refer to commissioning. In Force 5 the addition of 'Professional' (as the original author's no doubt recognized) is crucial. If you repeat the above exercise, plotting Force 5 on the Health Care Domains Model then you see how Force 5 works for nursing and remains to this day a great achievement as a yardstick for quality, assurance and retentive power.

In the almost 30 years since the research on the 14 Forces, I do wonder though if there is a need to imbue the following with magnetic properties:

• person-centred care;
• self-care;
• carers and public engagement;
• prevention;
• public (mental) health
• and informatics?

Yes, many of the above can be assumed to lie within the existing Forces 1-14. Health and social care are not static. Nursing has much to contend with from the level of the individual practitioner through to the group within an organization. The 14 Forces of Magnetism are well established in the USA and deservedly so, they clearly deliver.

In the political and economical heat of an economic recession, however; magnets may reach their particular^* Curie point. Then they cease to work.

The constant bangs and knocks of change, the incessant hammering of party politics and the 'market' on the door of "high quality nursing care" can also take its toll on magnetism.

Nursing needs to take care.

Related post on Healthcare IT News:

Top 10 trends for 2011 include IT, new care models

*OK it should be constant, but like our patients these magnets are not all the same - they have varying levels of vulnerability.

To follow some definitions from an olde book.

RCN Congress iii 2025 - Accountability for patients in ambulances

The resolution (with a reading list) on Accountability for patients in ambulances

- drew attention to language once again (yes, well there's a truism: what do you expect!). This time highlighting how corridor care is now variegated. In addition, politically you can circumvent addressing an issue, by referring to 'never events', and 'zero tolerance' as we read:

'This agenda item addresses the urgent issue of accountability, for both registered nurses and the organisations they work for, when patients are cared for in ambulances waiting to access emergency departments.

The resolution comes at a time when, across all four countries, there are unprecedented ambulance handover delays with patients left in vehicles which are neither appropriately staffed nor resourced outside overwhelmed emergency departments. Despite the prolific nature of this practice, there is no clear guidance on accountability. Who is responsible for the care and safety of those patients - the ambulance service, the hospital, the emergency department, or the individual registered nurse providing care?

These delays accessing care and the lack of guidance on who is accountable for the waiting patients, compromises the ability of health care staff to provide good quality care and risks patient safety. It also exposes registered nurses and other health care professionals to professionally, ethically and legally ambiguous situations. It could also contribute to the crisis in nursing wellbeing, raising issues such as moral distress and professional, emotional and physical burnout. It may, therefore, also impact the already perilous recruitment and retention.'

Student nurses, paramedics ... please take note: There is a paper to be written on Hodges' model and the gaps we encounter in health and social care. For Brian Hodges this started with the theory-practice gap; one of four original stimuli for the creation of the model. 

As the idealised standards, quality and safety of care being delivered are surrendered; this gap stands out as the virtual keystone.

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

individual - PURPOSES patient safety - distress nurse wellbeing emotional burnout moral distress personal ethics individual responsibilities	procedure delivered care - observation mattress, trolley .. ambulance design instrumentation, noise time - duration logistics - PROCESSES - handover physical resources - beds
communities of PRACTICE team working - coherence team experience - students THE DAMAGE - that is 'BOOK-PASSING' The public's - carer's experience (wither friends and family)	law - guidance - ambiguity POLICY professional accountability risk management organisational responsibility workforce recruitment & retention

Previously: 'RCN' : 'gap' : 'accountability' : 4Ps

CARDI conference Dublin 2011: Hodges' model - a poster element

Here is one element of the poster from last week's conference. This part is A3 in size and the linked preview below is to an archived copy on the Internet Archive. I will post the glocal version on W2tQ  in due course. As ever I wish I had more time to devote to producing such work. The symbol common to memory and giant global graph is intended to highlight a person's memory and the distributed 'memory' that is the Web. Such a representation can never capture all the subtleties involved, the overlaps, the contexts and perspectives.

The placement of some concepts is an invitation for reflection. For example, dementia and the use of anti-psychotic drugs also demands consideration of policy, liaison, primary-secondary-residential care interfaces, shared cared protocols, formal reviews, target behaviours, definitions of challenging behaviour, observation skills, clinical records, therapeutic interventions and the care environment ...  Some of the content, such as under Interpersonal Define 'safety', 'health'... seek to stress the same.

Acknowledgement:
Many thanks to the CARDI Committee for the opportunity to present, my employer Lancashire Care NHS Foundation Trust for study leave, and Prof. George Kernohan (Ulster.ac.uk) for assistance in supporting my attendance and in the production and printing of the poster. We plan to produce a paper based on the same.

"Train midwives as nurses" - Ockenden

Re. Ockenden Report

Catching up on the newspapers, I noticed in the Times reporting of Ockenden calling for midwives to train as nurses first. Provoking debate about nurse education.

Within maternity services there are problems with continuity of care and skills in dealing with complex cases:

'Maternal Deaths 

60. The Review examined 27 maternal deaths that occurred between 2006-2024. Five cases fell outside of the Terms of Reference of the Review. Of the 22 remaining cases, reviewers identified failures in care that may have or substantially impacted on the outcome in six deaths. 

61. The profile of maternal deaths at NUH over this period broadly aligned with the known demographics and causes as identified by MBRRACE. 11 of the deaths occurred to women living in the most deprived areas of the city and 14 occurred amongst women who were not white British.

62. The common failures reviewers identified that might prevent future maternal deaths included: listening to women and families and acting promptly on concerns; continuity of care particularly for those with additional social/medical complexities; robust clinical governance to ensure timely information sharing across organisations and prompt access to imaging for women presenting with concerning neurological symptoms.' xiv

AI Overview (Ecosia) suggests that although direct entry to midwifery has always been possible(?), the English National Board created the pathway some 39 years ago.

The Ockenden Report describes how in combination health systems, culture, leadership and training can contribute to compassion fatigue (p.313).

When you look at Hodges' model and our languages, a great many challenges for curricula, training and education programmes can be found. The most powerful of what can be progressive, or threats are invariably mechanistic:

• shorten
• bypass
• shortcut
• cutting corners
• short-circuit

Nursing must always move forward, continuous professional development is built on this principle. In the late 70s and 1980s post-registered qualifications were held in high esteem. Especially midwifery, paediatrics, health visiting, emergency and intensive care. 

Clearly, decision and policymakers can underestimate the value of basic nurse training. Having an idea since childhood is brilliant, but at interview saying you're compassionate and want to make a difference will soon be tested. Sometimes as a student rather bluntly, as with a first placement in forensic nursing. I wonder how many students have been lost there? I'm sure the majority will cope, manage, enjoy and prosper, but I've seen the student peers who miss these cohort members on subsequent learning experiences. What preparation is employed?

Basic nurse training, is just that. Demonstrating competence in communication, awareness of basic needs and how these are expressed behaviourally. What interpersonal skills and knowledge are needed. As highlighted before, the director of nurse education worried about those of us who worked as nursing assistants risked being trained in poor care. Not recognising 'bad practice', a 'poor attitude', not using observation and most important of all listening: to what is said and unsaid. When I started I remember thinking about not responding - as individually programmed to do so, through a reflex action. That was a worry back then. 

While the news in the Ockenden Report is bleak. The depth of the report (for me) is manifest in identification of not only socioeconomic factors, but sociotechnical too (with five mentions) and the critical interplay of seeing (and hearing!) the individual amid the collective:

'2. Fetal monitoring

Rather than reflecting simple failures of individual interpretation, growing evidence suggests that intrapartum fetal monitoring is best understood as a complex sociotechnical practice, shaped by system design, workload, team dynamics, guideline variability and organisational culture.119 Continuous CTG itself has well-recognised limitations, including poor specificity for predicting long-term neonatal outcomes and substantial inter- and intra-observer variation in interpretation.5 Reviews of intrapartum care are therefore unavoidably influenced by retrospective bias, with greater apparent clarity afforded by knowledge of the outcome than was available to clinicians at the time. 

However, despite this, a sociotechnical understanding does not negate the importance of examining individual cases in which intrapartum monitoring was demonstrably substandard. National inquiries and confidential reviews repeatedly describe cases involving sustained failure to recognise pathological fetal heart-rate patterns, delayed escalation despite repeated triggers, and missed opportunities for timely intervention. 2,3,120,121 These cases cannot be explained solely by the inherent limitations of CTG or by hindsight bias.' p.143.

It is quite shocking to hear this conclusion: the need to train as a nurse first. Counterarguments: where is the evidence(?!) - have followed. But then if you undervalue and miss the fundamentals (see Hodges' model!) then individuals, families, communities, students, practitioners, services and systems suffer.

Previously: 'maternity' : 'report' : 'safety'

The critical pathway leads to ...?

I missed the most salient information on this book's cover - at least for me. My copy is secondhand, but I picked the copy up recalling Dr Walsh's many publications on models of nursing.

The critical pathway for me is plural. It would include, the CPN(Cert.) course when I first encountered Hodges' model in 1987-8. Plus the fact that the pathway is not unidirectional, with some backward steps and reviews, but is multifold. Running the axes of Hodges' model to - pre-op, surgery, post-op, rehab ... we can add the whole corpus of nursing, social, self, and global health care.

The cover is of course illustrative, intended to support the title and suggest an explicit critical pathway. Apart from possibly pointing to collaboration "Mr Jones ... Let us discuss your critical pathway!" what has changed? Since the book's publication in 1997, we need health care services and systems to be sustainable. We are bit late here. Mr Jones is already a 'patient', bedecked in dressing gown and slippers.

This critical pathway needs to be replaced by one informed and oriented towards Mr Jones as self-caring citizen. This is of course easier said than done in policy terms. While governments globally and institutions stress the need for health literacy, informed life style choices, self-care, health promotion and prevention how much progress is being made? Nutrition remains a profound issue.*

The environmental challenges of climate change, pollution and waste disposal are seemingly contested even as the effects and cost of non-action are increasingly obvious.

The policy of 'care in the community' even while incomplete in the community, has provided me with a stimulating, challenging and rewarding career 1985 ... In the 21st century though, we have to ask of the assessment of mobility to follow and effort of the up-hill walk to 'home' begs the critical pathway that is now Planetary Health.

<>

Several points from Walsh (1997):

'Introducing a model to a clinical area is not an easy task to be undertaken lightly, as it involves fundamental changes in the way staff think and work. Luker (1988) has suggested that each nurse carries around their own informal model of nursing which guides their practice. It is probable that a formal model will be significantly different, although these differences can be minimized by full consultation and involvement with staff to ensure that the model chosen reflects their views of nursing as far as possible.' p.36.

Hodges' model can be 'carried around'. In truth it not strictly a model of nursing. Its scope extends beyond nursing and yet the model can incorporate thought about the patient, nurse, environment and what health, illness, recovery and self-care entail. Hodges' model is meta-cognitive and meta-conceptual, and (very) capable of mapping the terrain (p.26) of nursing from these and other perspectives. A nurse's 'views of nursing' will be dictated by the situation presented to them. Hodges' model can be retrospective, prospective and operate in the here-and-now: situated.

'There is a further point, however, that follows on from Luker's observation for expert nurses have an internalized model of care which is unique to them, it is possible that they may have internalized some practices which are outdated, taken for granted or inappropriate (Paley, 1996) but which are never made explicit as their care is not based upon a commonly understood model of nursing. This notion of every nurse having their own model therefore can lead to the situation where outdated rituals can be propagated under the guise of expert practice. Having a series of explicit models whose aims and ideas are common knowledge, shared by all, opens up care to critical scrutiny in a way that is not possible if each nurse has their own private internal model.' p.37.

Hodges' model can be used with other models, conceptual frameworks and systems across disiplines. Hodges' model is not intended to be prescriptive or prospective. It can be utilised for learning and unlearning. As a registered General Nurse who studied in the 1980s this does not mean I would be competent and safe to practice now. Continuing professional development, mandatory training and revalidation of nursing registration are all geared to support professional practice that has currency, validity, and is safe.

If nursing ever needed a commonly understood model ...?

'It will be apparent from the previous sections that use of a model will lead nursing into some new and unfamiliar territory that will involve seeing the patient in a more holistic fashion'. p.63.

'The nurse may find that models start to identify environmental problems whose solutions lie beyond the boundaries of nursing at present. This is particularly true of the community nurse.' p.63.

Walsh's concern here is the immediate community, but we can recognise the prescience of environmental problems here. Plus the need for the POLITICAL domain in Hodges' model:

'On a larger scale still, perhaps some patient's problems have their origins in political decisions made by national govemment or perhaps it is the factory down the road producing unacceptable levels of pollution. If nursing models make us recognize the political and environmental causes of some patient problems, there should ee no logical reason why nursing should not go forward into theee arenas as a legitimate part of nursing intervention.' p.63.

'There are senior NHS managers and health academics in so-called 'policy thínk tanks' who simply do not recognize the value of nursing and see only a collection of simpie tasks which anybody with an NVQ level 2 can perform. Nursing therefore has to demonstrate its worth; it has to evaluate what it is doing for patients.

Here it is important to remember that the care given may be very different from what is written down. Consequently, how a nurse evaluates care mentally may be very different from how this care is recorded in nursing process documentation. ...' p.64.

Hodges' model can (imho) have a role in argumentation for the quality and scope of healthcare, for nursing as a profession, evaluating and assuring nursing's values in the constant that are the demands of complexity and change. The (several) determinants of health are the other constant.

Mike Walsh (1997) Models and Critical Pathways in Clinical Nursing. London: Bailliere Tindall.

Luker K. (1988) Do Models Work? Nursing Times, 84 (5), 27-29.

Paley, J. (1996), Intuition and expertise: comments on the Benner debate. Journal of Advanced Nursing, 23: 665-671. https://doi.org/10.1111/j.1365-2648.1996.tb00035.x

*Jones P, Wirnitzer K. Hodges’ model: the Sustainable Development Goals and public health – universal health coverage demands a universal framework. BMJ Nutrition, Prevention & Health 2022;5: doi:10.1136/bmjnph-2021-000254

Wirnitzer KC, Motevalli M, Tanous DR, Drenowatz C, Moser M, Cramer H, Rosemann T, Wagner K-H, Michalsen A, Knechtle B, Fras Z, Ritskes-Hoitinga M, Marques A, Mis NF, Stanford FC, Schubert C, Goswami N, Leitzmann C, Fredriksen PM, Ruedl G, Wilflingseder D, Lima RA, Kessler C, Jeitler M, Khan NA, Joulaei H, Fatemi M, Knight A, Kratky KW, Palmer KK, Haditsch B, Jakse B, Kofler W, Pfeiffer T, Cordova-Pozo K, Tortella P, Straub S, Lynch H, Schätzer M, Krishnan A, Fathima A. S, Gatterer L, Kriwan F, Abhishek M, Nandgaonkar H, Nandgaonkar S, Adedara AO, Haro JM, Gericke C, Neumann G, Akhtar A, Rashidlamir A, Thangavelu M, Ngoumou GB, Perpék É, Klaper M, Bhattacharya B, Kirschner W, Bessems KMHH, Jones P, Peoples G, Bescos R, Duftner C, Seifert G (2025). Toward a roadmap for addressing today's health dilemma–The 101-statement consensus report., 

Frontiers in Nutrition, Volume 12:1676080. doi: 10.3389/fnut.2025.1676080. https://doi.org/10.3389/fnut.2025.1676080