World Drowning Prevention Day 25th July 2024

Every year, an estimated 236,000 people drown, making drowning a major public health problem worldwide. Drowning is one of the leading causes of death globally for children and young people aged 1-24 years. Drowning is the 3rd leading cause of unintentional injury death, accounting for 7% of all injury-related deaths.

The global burden of death from drowning is felt in all economies and regions, however:

• low- and middle-income countries account for over 90% of unintentional drowning deaths; 
• over half of the world's drowning occurs in the WHO Western Pacific Region and WHO South-East Asia Region; 
• drowning death rates are highest in the WHO Western Pacific Region, and are 27-32 times higher than those seen in the United Kingdom or Germany, respectively.

World Drowning Prevention Day

World Drowning Prevention Day, declared in April 2021 by General Assembly resolution A/RES/75/273 <https://undocs.org/en/A/RES/75/273>, is held annually on 25 July. This global advocacy event serves as an opportunity to highlight the tragic and profound impact of drowning on families and communities and to offer life-saving solutions to prevent it.

Find more information in the following link: 

https://www.un.org/en/observances/drowning-prevention-day 

In your country, are there any initiatives to prevent drowning?

Here are some of the measures shared at the United Nations web site.

• installing barriers controlling access to water;
• providing safe places away from water such as crèches for pre-school children with capable childcare;
• teaching swimming, water safety and safe rescue skills;
• training bystanders in safe rescue and resuscitation;
• setting and enforcing safe boating, shipping and ferry regulations;
• improving flood risk management.

My source (with video added above and Hodges' model below):

Jackeline. HIFA-Spanish Moderator

HIFA profile: Jackeline Alger, MD, PhD, is a parasitologist associated to the Department of Clinical Laboratory of the University Hospital; Executive Director of the Antonio Vidal Institute for Infectious Diseases and Parasitology; Tegucigalpa, Honduras. HIFA Country Representative of the Year for the years 2015 and 2018. Email jackelinealger AT gmail.com

The bullet points above mapped to Hodges' model, with additions (italics).

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

teaching swimming, water safety and safe rescue skills training bystanders in safe rescue and resuscitation awareness of risk situations confidence to learn to swim	installing barriers controlling access to water providing safe places away from water such as crèches for pre-school children with capable childcare improving flood risk management
teaching swimming, water safety and safe rescue skills training bystanders in safe rescue and resuscitation family and community impacts SOCIO-	funding - prioritisation setting and enforcing safe boating, shipping and ferry regulations improving flood risk management facilities for safe & effective teaching -ECONOMIC   LMICs

Previously 2022

RCN Congress 2026 & RCN North West Multicultural Group (NWMG)

England's North West is certainly in the news at present, on two counts:

1. The current Labour party machinations in the Makerfield ward;
2. and RCN Congress in Liverpool.

 As I attend Congress a key focus is the debates and how I can relate these to Hodges'model - (with some links to previous posts):

1. Nursing as a STEM profession
Matter for discussion submitted by the Eastern Board
That this meeting of RCN Congress discusses the recognition of nursing as a STEM (Science, Technology, Engineering, and Mathematics) profession, valuing the scientific, technical and analytical expertise of nurses.

STEM - science : technology : engineering : mathematics

2. Safe, ethical, person‑centred nursing
Resolution submitted by the Cheshire Branch
That this meeting of RCN Congress calls on RCN Council to urgently develop and implement a UK‑wide framework for realistic person‑centred care, ensuring that nursing practice is safe and ethical.

safe : ethics : person-centred 

3. Regular redeployment
Matter for discussion submitted by the Wiltshire Branch
That this meeting of RCN Congress discusses the impact of the daily redeployment of nursing staff on morale, team work and patient safety.

re- deployment

4. Unpaid hours
Matter for discussion submitted by the North East London Inner Branch
That this meeting of RCN Congress discusses the culture of nursing staff missing breaks and working beyond their contracted hours.

work

5. National safety standards for lone working
Resolution submitted by the Health and Safety Reps Committee
That this meeting of RCN Congress calls on RCN Council to lobby for the implementation of national safety standards for lone working, ensuring access to appropriate safety equipment, technology and protocols to protect staff across all care settings.

lone working

6. Accountable, compassionate and psychologically safe leadership
Matter for discussion submitted by the Cheshire Branch
That this meeting of RCN Congress discusses how the RCN can help create a culture where accountability, compassion, and psychological safety coexist, enabling managers to lead effectively while ensuring all staff feel respected and protected.

accountability : compassion : leadership 

7. Misinformation in health care
Matter for discussion submitted by the Women's Health Forum
That this meeting of RCN Congress discusses misinformation in health care and the impact this has on the nursing workforce.

misinformation : information disorder

8. Confidence to address racism
Matter for discussion submitted by the South West London Outer Branch
That this meeting of RCN Congress discusses how to build the confidence of nursing staff in addressing racism.

confidence : racism

Once again the North West Multicultural Group will have a stand:

The RCN North West Multicultural Group (NWMG) creates a community for members across the region from multicultural ethnic backgrounds to connect with each other, share their lived experience, knowledge and diverse ideas that help drive change around racism to ensure that their various organisations is the best place to work.

Membership is open to RCN members of Royal College of Nursing from multicultural backgrounds and their allies.

Mission statement: 

The aim of the North West Multicultural Group is to stand against racism and discrimination by using members lived experiences, encouraging organisations to be anti-racist and with the support of allies.  

Aims and objectives: 

• To raise the issues around race, discrimination and equality in the workplace and to find potential solutions. 
• To challenge misconceptions about people from different ethnic backgrounds.
• To recognise the skills and contribution to care for people from all backgrounds make.
• To acknowledge that racism is a social construct that needs to be eradicated together.  Together we are stronger.
• To be a platform for black, Asian and minority ethnic staff and allies to work collaboratively to address racism in practice.
• To help amplify the voice black, Asian and minority ethnic staff.
• To be role models, set examples as allies and develop confidence.
• To provide training and support about anti-racist practice.
• To work with the RCN to support campaigns to make sure communication is fit for purpose and acknowledges any cultural differences. 

Your executive team:

Chair: Olanike Babalola
Vice Chair: Susan Owen-Naz
Communications Officer: Mark Anthony

9. Advanced nursing practice
Resolution submitted by RCN Council
That this meeting of RCN Congress agrees that the RCN will act upon attempts to undermine advanced nursing practice.

advanced : practice : theory

10. Protecting nurse education
Resolution submitted by the Education Forum
That this meeting of RCN Congress asks RCN Council to lobby UK governments to protect nurse education from university sector economic pressures.

protect

11. Quality of clinical placements
Matter for discussion submitted by the Students Committee
That this meeting of RCN Congress discusses ways in which the quality of clinical placements can be ensured and consistent across all 4 countries.

quality : placement

12. Bank rates
Resolution submitted by the South Yorkshire Branch
That this meeting of RCN Congress demands that employers pay nursing staff bank shifts at their substantive rate.

pay

13. Are external reviews meaningful?
Matter for discussion submitted by the Midwifery Forum
That this meeting of RCN Congress discusses whether external reviews and inquiries are genuinely driving meaningful improvements in safety across health and social care.

inquiry : review

14. Improving acute mental health crisis services for children and young people
Resolution submitted by the London Board
That this meeting of RCN Congress calls on RCN Council to lobby UK governments to improve the provision of services to children and young people presenting in acute mental health crisis.

children : mental health

15. Access to specialist pain services
Matter for discussion submitted by the Pain and Palliative Care Forum
That this meeting of RCN Congress discusses access to specialist pain services and the role of the registered nurse in caring for those in pain.

pain

16. Palliative and end-of-life care
Resolution submitted by the Pain and Palliative Care Forum
That this meeting of RCN Congress calls on RCN Council to lobby UK governments to ensure everyone living across all 4 nations has access to specialist palliative and end-of-life care.

palliative

17. Accessible and affordable travel
Matter for discussion submitted by the North Central London Inner Branch
That this meeting of RCN Congress discusses what accessible and affordable travel means for the nursing workforce.

18. Uptake of physical health checks
Resolution submitted by the Public Health Forum
That this meeting of RCN Congress requests RCN Council to lobby UK governments to improve the uptake of physical health checks for people with learning disabilities and serious mental illnesses (SMI).

serious mental illness (SMI)

19. Eye donation
Matter for discussion submitted by the Greater Glasgow Branch
That this meeting of RCN Congress discusses the role nursing has in eye donation in end-of-life care planning.

eye : vision

20. 35-hour week
Resolution submitted by the Lothian and Borders Branch
That this meeting of RCN Congress calls on RCN Council to instigate a campaign for a maximum 35 hour working week for the nursing workforce.

21. Inappropriate delegation
Matter for discussion submitted by the Berkshire Branch
That this meeting of RCN Congress discusses the delegation of health care tasks to school staff and non-health care professionals.

22. Access to medicinal cannabis
Matter for discussion submitted by the Cheshire Branch
That this meeting of RCN Congress discusses the impact of current NHS prescribing practice on access to medicinal cannabis.

medicinal cannabis

23. SPA time
Resolution submitted by the Wiltshire Branch
That this meeting of RCN Congress calls on RCN Council to lobby for the inclusion of Supporting Professional Activities (SPA) time in all nursing job-plans.

See: https://www.rcn.org.uk/Congress/Agenda 

Are there any lessons from this exercise? Well, I have no posts tagged 'donor', or 'medicinal cannabis' - to make an important distinction. Something to correct and try to follow this week. 

See you there ...?

(I may need to reduce the link-count here.) 

iii RCGP’s 7th Health and Justice Summit ...

Returning to Juliet Lyon CBE, Chair of the Independent Advisory Panel on Deaths in Custody, who presented ‘Keeping Safe – how consultation with women and men in prison and health and justice professionals informs our work and advice to ministers.’

In February this year the Independent Advisory Panel on Deaths in Custody (IAP) and the national newspaper for people in prison, Inside Time, began a ground-breaking collaboration - Keeping Safe - to help keep people in prison safe. Supported by the Samaritans and Prison Radio, the IAP called on Inside Time readers to say how best to prevent suicide and self-harm. Prisoners’ recommendations in this Inside Time special report reflect evidence from, and recommendations made repeatedly by, amongst others, the Prisons and Probation Ombudsman, HM Chief Inspector of Prisons, the Chief Coroner and the National Audit Office.

Ms Lyon spoke of the clinical context, hope and time:

What was done in the  ::   Being in Prison  ::    What might be done in the

Past                        Now                             Future

Mention was made of a 'Keeping Safe' event in February 2020. If I learn more, I will add details.

Mark Langridge took us through some technology developments in healthcare as Care UK National Lead Pharmacist:

Socrates (with reference to 5-domains of well-being)
PharmaSelf24
PrisonAssist
Turning-On

There was discussion of "Opt-out" in respect to population screening for antibody positive screening tests and how the question is framed:

"Want your bloods done, luv?"

"We test everyone because    ...

is that OK with you?"

On day 2 Suzy Diamond-White, Governor at HMP Eastwood Park shared management experiences and the quest for change in ‘Delivering Health and Wellbeing in a Women’s Prison’

A look at how health services are delivered within the operational demands of daily life at Eastwood Park given its complex population and wide geographical catchment area. How we keep wellbeing on the agenda to support our contracted health teams. What is so specific about a women’s prison? What needs to be overcome to ensure equivalent service to the community.

Gender was obviously fundamental here, the fit and appropriateness of P.E. kits, the procurement and supply of sanitary towels and incontinence pads. What is 'hygiene' being accounted for through a 'cleaning' budget and other historical legacies to be challenged. The geographical range of Eastwood Park across nine counties and all the consequences for family and children. Talk of prison as a punishment and the public's view was echoed a few times at the summit.

Elizabeth Moody, Deputy Ombudsman at Prisons and Probation Ombudsman provided more reflection on deaths in custody, stressing the families affected by and need for action and lessons to be learned. High profile cases were mentioned in several presentations. The talk gave me a sense on one hand of what families must go through, especially when circumstances suddenly engulfs an individual in the criminal justice system. The work that independent agencies do behind the headlines and sometimes in the midst of them

Chantal Edge, NIHR Clinical Doctoral Research Fellow for Department of Epidemiology and Public Health described research on “Systems barriers to telemedicine in prisons”.

Experiences of systems barriers (prison and hospital/community) encountered in England whilst attempting to operationalise a local prison-hospital telemedicine model, alongside broader evidence on prison telemedicine implementation barriers drawn from a systematic qualitative literature review of published prison telemedicine evidence.

I was late arriving to this session. As per my thoughts concerning Dr Matthew Langley's presentation the potential socio-technical studies might provide some insights?

Although it is also a commercial vehicle, Raconteur published with The Times had a special report on 5G in June. In a similar way to my references to the 5-Care-Domains of Hodges' model, many people talk of 5G and its speed, without fully understanding the change and opportunities this can bring. The report's summary:

"5G is so much more than faster 4G, but the extraordinary hype surrounding it has left many confused over what it will actually do for them. The 5G special report, published in The Times aims to shine light on this, exploring how 5G can transform healthcare and make smart roads a reality ahead of autonomous cars. It covers how to address public concerns over the health impacts of 5G and examines whether the rush to be first in the 5G race is a fool’s errand, with comment on how it might be better to deploy 5G best, rather than deploy it first. Also featured is an infographic measuring the true impact of 5G and looking at the sectors which stand to benefit the most ..."

Chantal provided some copies of an associated paper:

Edge, C., Black, G., King, E., George, J., Patel, S., & Hayward, A. (2019). Improving care quality with prison telemedicine: The effects of context and multiplicity on successful implementation and use. Journal of Telemedicine and Telecare. https://doi.org/10.1177/1357633X19869131

Rachel Gibbs "Equalizing Spaces"

Rachel Gibbs, Assistant Director for Prison Healthcare Services for Northern Ireland shared a travel fellowship “Equalising Spaces”.

Rachel Gibbs was awarded a Winston Churchill Memorial Trust Fellowship in 2019. She will share learning from her visits to Prison Healthcare services/Transitions clinics/Harm reduction rooms in California, North Dakota, New York, Barcelona, Geneva and Stockholm over an eight week period in order to being back innovative ideas to the UK. She will share some of the user involvement work happening in Northern Ireland.

Churchill Fellowship

The title of this session including 'spaces' had my immediate attention and did not disappoint. Rachel's Gibbs also provided help in making me feel a little less guilty in the future. Rachel highlighted and reminded me of the value of travel in the exchange, transfusion and diffusion of ideas, a difficult equation to resolve in these flight-shaming days.

Rachel Gibbs - findings

I do wonder what a global consensus would be on models of care, nursing theory and what other continents have to say (if anything?) on this topic that might inform my study of Hodges' model. Rachel recounted her travels and learning not just from her peers but from prisoners and ex-prisoners. Existing awareness of international health and justice provision was used to focus countries to visit.

Rachel shared her time with:

Transitions Clinic Network (TCN), USA.

and 

One Day at a time
Empowering youth to lead positive lives

Hodges' model repeatedly 'takes' me to spaces of all kinds and also transitions:

Life course - infant - child - teens - adult - older adult - end of life

Life course - infant - child - teens - adult - older adult - end of life :: Diagnosis X (Rare?)

Health - Social Care

Critical information giving :: Pre - Post

Adult service - Older Adult Services

Looked after Children - Adult

Younger Adult, Adult, Older Adult :: Early Onset Dementia

Home care - Day care - Respite care - Residential Care

Continuing Health Care

Justice and Health

Veteran - Civilian

Risk

Formative education - Lifelong learning

Health - Trauma - Intensive Treatment - Return Home

and other Transitions (Prevention!) ...

We often think of tools and the need for them to be ready to hand, as in organising your workspace. Increasingly as the list above suggests there is a need for tools to help keep things 'close to mind' also.

Professor Graeme Henderson (School of Physiology, Pharmacology and Neuroscience for The University of Bristol) gave a serious and yet entertaining talk on“Why are fentanyls so deadly?”

Fentanyls are highly potent opioid agonists. Only small quantities are required to produce their effects and this may make them attractive drugs for smuggling into prisons. fentanyls have pharmacological properties that make them more likely to lead to overdose than other opioids – in addition to their high potency and rapid onset of action these drugs induce respiratory muscle stiffness making it difficult to breath, are less sensitive than heroin to naloxone reversal and may show reduced cross tolerance to other opioids.

Prof Henderson provided statistics that had you paying notice, supporting the first answers to the title:

• High potency
• Faster rate of onset of respiratory depression
• Muscle stiffness (wooden chest) making it harder to breathe
• Lower cross tolerance between heroin and fentanyl
• Resistance to naloxone reversal

The Chairs for the summit had quite rightly drew delegates attention to the exhibitors, so I was a bit late again here. The photo is not very good, but brings home the potency of fentanyl. (That is Prof Henderson in the biohazard suit.)

... (still) to be completed - part iv to follow ...

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

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

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

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

HRH The Duke of Edinburgh RIP

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

My source: RCNi via twitter: 

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

High quality nursing care: Staff numbers + Management + Complexity = Goat (Rabbit or Duck)?

When did someone last get your goat?

For me I owe a vote of thanks to Mr Harry Cayton in the (print) Health Service Journal, 2012

 The wrong answer to the wrong question. 

I know it's hard to believe, but I've been simmering for a year and a half; especially watching, listening and reading about the NHS and the state of nursing in the media.

The subtitle of this short opinion piece (p. 16-17) reads:  

"There is no direct link between staff numbers and care quality, 

so a minimum staff ratio is a fig leaf performance measure." 

Online it is: 15 March 2012 'Mandating staffing levels is not the answer to reducing poor care'
 - so you get the gist...?

As a nurse, the subtitle did its trick, it rubbed against the whole tree of experience, not just a branch or two.

It is a long time since I was a deputy charge nurse on what was then 'psychogeriatrics'. Relatives would arrive on the ward for the first time and start to weep. We had to reassure and demonstrate that we cared not just in words, but actions: nursing care. We got things wrong: teeth, clothing. ... A variety of 'lists' and books signified institutional care. That Victorian institution is no more, this is progress. The change has been amazing. It is also a long time since I was a charge nurse on acute female admission. The thing is numbers always counted. How many times did we, the team, wonder what we could have done with another two, or four hands? Within mental health care risk is a positive and negative companion to all our patient contacts. There may be confusion in numbers, but there is safety too.

You know that numbers do count.

As Mr Cayton points out - poor management is a primary factor in poor care. He quite rightly refers to the complexity that arises. As I have posted here several times, staff attitudes and skills are central to the quality of care that follows. Mr Cayton highlights the same.

If evidence based health care is so powerful why are we still deliberating upon this?

This isn't just complex, it's complex as in complexity science. In the late 70s - 80s and even today there is discussion of dependency and workload measures. There is a real illusion at work.

As a nurse in this context you recognised the limitations of know thyself. You have to know yourself, especially: can I delegate effectively? Am I a manager's manager? How can I balance the office and the ward?

The limitation is: do I know my team? Since the 1980s I wonder how well ward managers know their team. What is the impact of agency workers - nursing and medical? How has this workforce development influenced the work and performance of the FY1s (foundation - first year doctors)?

We ensured we had covered the 'basics' as comprehensively as we could. Everyone was safe, warm, clean, skin clean and intact, dressings completed, fed, watered, given a smile, (if possible) gave a smile and as much reassurance as could be provided. Any care outstanding was reported to the next shift to ensure it was completed as a priority.

Returning to the question of evidence and the illusory, chimeric character of this debate. There is a great post-grad student essay on the relative and normative dimensions of nursing staffing to be written. Health services must wrestle with standards, local responsiveness, person-centredness, outcomes and umpteen other requirements in care delivery. If funding (staffing!) results in nurses having an arm tied behind their back, perhaps mandated staffing levels does the same for managers?

There is undoubtedly much to consider in relation to the equations that abound in staffing numbers and quality of care. As we think of trees of knowledge,  experience and branches, let's remember the leaves; everyone unique.

Update: 24 Aug 2013
News, Health Service Journal, 23 August 2013, Minimum safe staffing work yet to begin, 123, 6364, p.7. 123

"We need tools that are relevant to the care environment; we need leadership locally that has the resources and responsibility to meet the levels the tools are demanding and we need some degree of professional responsibility and decision making at ward level."
(Prof. Jim Buchan)

Additional links:

Policy Unit. Royal College of Nursing (2010) Guidance on safe nurse staffing levels in the UK
http://www.rcn.org.uk/__data/assets/pdf_file/0005/353237/003860.pdf

Safe Staffing Alliance

Kay, J. (2013). Making the case for more nurses, Health Service Journal, 123, 6355, 30-31.

Donnelly L., Mulhern, M., NHS pays £1,600 a day for nurses as agency use soars, The Telegraph, 14 Jul 2012.

http://hodges-model.blogspot.co.uk/2013/03/bbc-horizon-ii-processes-step-this-way.html

26/02/2014:
New [Lancet] study shows degree level nursing education cuts unnecessary hospital deaths
http://www.councilofdeans.org.uk/2014/02/new-study-shows-degree-level-nursing-education-cuts-unnecessary-hospital-deaths/#comment-28

'Safe space' - which one?

 Individual
  |

     INTERPERSONAL    :     SCIENCES               

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

SOCIOLOGY  :   POLITICAL 

|

GROUP

psychological safety

physical safety

social safety

"NHS staff will be able to speak out about mistakes without fear of reprisal for the first time, thanks to a new investigation unit with "safe space" powers. The Health Services Safety Investigations Body (HSSIB), which was launched last week, has been granted a remit that in effect means any testimony or evidence given to it by doctors, nurses and other staff medical staff will not be handed over to another agency - such as the police, a coroner or the General Medical Council - unless the High Court rules that it must."

Lintern, S. 'Safe space' unit to protect NHS staff reporting medical errors, The Sunday Times, 22nd October 2023, p.11.

"No safety without emotional safety" by Veale, et al. (2022)

 INDIVIDUAL
|

 INTERPERSONAL    :     SCIENCES               

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

SOCIOLOGY  :   POLITICAL 

|

GROUP

psychological needs (risk) inc. threat processing - treatment of interpersonal violence 'therapeutic emotional safety (re-traumatisation) control behaviour severe panic with flashbacks, dissociation, and visual hallucinations	physical needs (RISK) 'low intensity touch' environment' ... tepee - in room my safe space physical safety (safe room) to increase physical safety privacy, lighting, doors, window
lived experience family - relationship experience (touch) 'atmosphere'? change in culture, positive risk-taking person-centredness, family orientation in 'team' Leadership 'therapeutic community' Open Dialogue	CONTROL: 'take away' - autonomy, responsibility policies - abuse risk, 'protect' patients and staff regulatory reform in-patient care, pets - policy parity of esteem Access (still) to therapies, CBT Institutional risk Alternative protocols

David Veale, Eleanor Robins, Alex B Thomson, Paul Gilbert, No safety without emotional safety, The Lancet Psychiatry, 2022, ISSN 2215-0366, https://doi.org/10.1016/S2215-0366(22)00373-X. (https://www.sciencedirect.com/science/article/pii/S221503662200373X)

My source:
https://twitter.com/tadhg50/status/1596901626765529091?s=20&t=FJe9qpYUrxHN2yxWEWLUdQ

The purposes of Hodges' model is to identify the concepts that have salience clinically, to the person, be they - patient, carer, student ... and then to integrate care, to draw the care domains together into a 'whole'.

Four original purposes of Hodges' model: 

1. Reflection, reflective practice, critical thinking
2. Person-centred care
3. Holistic - integrated care
4. Bridge the Theory - Practice gap

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

Nursing process: a lesson for interface developers

Back in the 1980s when the nursing process first appeared in the UK, amongst the pioneering early adopters there were nurses who were also worried. Would the nursing process with its mechanistic connotations lead to the person, the patient - literally being processed? There is a lesson here for nursing (health and social care) IT systems / interface developers ...

They really are star performers you know, regular high-wire runners. They have to make things simple, safe, efficient, fit for purpose and yet also deal with complexity as they juggle multiple contexts and second guess the psychological state of not just one user (crucial as that is), but several groups (disciplines, beginner-specialists, user roles and security...).

In Tidwell's Designing Interfaces the first chapter is more a psychology primer than pure IT text. The first pattern is safe exploration (and there's much more too).

This week someone e-mailed me and stated that the website and links (in particular) are 'daunting'. While for me the website and links pages have been an emergent pursuit, for 1st-xth time visitors .... well; I have to agree.

Thinking beyond a new site for an archive and book project - this is the trick, I suppose. How do you make a site or information system inviting and put the user at ease? How do you hide complexity until it is appropriate to do the non-trivial things? In order to capture data quickly and efficiently at the point of care how can those static check boxes and drop-down lists duck and weave the user's perception that:

1. They as a professional are being de-skilled;
2. or that the patient (person!) is indeed being 'processed'?

That's not just one tightrope, but several ...

Elderly Care: "Follow me please" along the gangway

It goes with the job, seeing people in residential care and nursing homes. The past few weeks walking through several care facilities - corridor-lounge-corridor - you pass a series of open doors, an invite to gaze that way. (People do ask to have their doors left open and visitors should not be able to walk past open doors if privacy and dignity are at risk?) Walking along - a smile, nod of the head, wave of the hand it's like a gangway.

Recently, though it was a case of 1, 2, 3 and counting: residents sat in their rooms; chair, wheel chair, special chair bound.

A gallery of still-life studies. So many heads bowed, cast as life and world-weary statues. So many aged variations of The Thinker.

The homes and their staff do the best they can, some employ people dedicated to 'activities'. Despite this, it's not easy for many new carers to appreciate the value in engaging people who are disoriented for TI:ME, PLACE and PERSON in chit-chat or a group activity when five minutes later they have forgotten all about it. People are referred to mental health services because they have a mental health 'problem' and yet in many cases their bags are packed and they are ready to take you on a journey: if you care to listen.

We seem to focus on the cognitive value of the things we do, but is this a variation of task orientation that delivers a concrete output (PROCESS vs PURPOSE again)? What about the emotional value of the things we do and the possible benefits, whether visible or intangible? ALL work and the effort it requires carries a price and despite the forgetting, the emotional engagement and safe social contact can still make a real positive difference to people. The price paid by residents in being engaged in conversation, can reduce any sense of alienation, loneliness and the aggression and agitation that can follow.

What do I mean 'safe' social contact? Many people in care are disinhibited; they say things to their fellows and staff that are very personal and upsetting. Cognitive decline is a fact of life, but even for people diagnosed with dementia, the damage done varies from person to person. For many they are profoundly impaired and yet their personality flickers through and with it sensitivity to things said by their peers. Remember those anxious moments in the play ground? Social mores are deeply ingrained in us. Maybe this is why for youngsters the current spate of e-bullying is having such a impact. Bodies may be battered and worn, but INTRA - interPERSONAL and SOCIAL exercise mediated by carers (and relatives!) can pay longer term dividends.

In between care needs that also demand quiet, rest and sleep and our need to be realistic and objective; personal and group engagement can I'm sure make a real difference. It depends on the resources + the right attitudes to make it happen. To see the person not the statue.

Even if only for a few moments
bringing statues back to life is real magic.
Walking the gangway is one thing,
but residential care should not be the gangplank
as it is so often portrayed for residents or staff.
Converse-2-conserve.

Rodin image original source: http://users.ox.ac.uk/~ball0888/oxfordopen/Rodin.htm

Nursing management consultants & being optically challenged

Being somewhat optically challenged at present (need new glasses!) I have nonetheless managed to sort some old papers. I came across a more recent news item from the Nursing Times 8 September, p.3 by Sally Gainsbury. What use is late news?

I raise this now because public sector health finance provides the impetus, so this subject is perpetual motion. It is also reported ongoing by HSJ. I refer to this not to take sides, but to acknowledge that politically there is a need to make decisions and find the required £20bn efficiency savings. The news line reads:

DH told 1,500 district nurses could go with no damage to patient care

The item focuses on a report for the DoH produced by McKinsey management consultants. The government has distanced itself from the reports recommendations, but the need for action remains. The Nursing Times news item includes two clocks (with the total nursing time available depicted as 1 hour) that break down the time spent on patients on general medical wards and community wards. While this is just one aspect of a report of more than 100 pages, the findings are of great interest. ...

GENERAL WARD: 15 mins Physical care; 10 mins Psychosocial care; 35 mins non-patient care.
COMMUNITY NURSES: 17 mins Antenatal activities; 13 mins Postnatal; 27 mins npc; 3 mins other and classes.
I have not worked on a general or mental health ward for a long time, but I was surprised to see the time spent on patient being less on the wards than the community - 25 minutes v. 30 minutes. There are challenges in comparing different clinical areas, but I would have thought travel, administration - including paper and e-record data entry would impinge much more on community. On mental health wards there has been an effort to free nurses to nurse - with protected time? So pause for thought there - but only for a moment....

Thinking about community - providers will no doubt vary in the way (district) nursing teams are organized, the location of their bases and how that impacts average journey times. Districts also vary in the way the population is distributed, especially those neighbourhoods were social and economic deprivation is higher and need may be increased.

This is why access to GIS (geographical information systems) by team managers and members is crucial and should not just be some esoteric academic and intelligence artifact. While we should not under estimate the potential use of GIS to inform inpatient care, it is community services that are best placed to benefit from improved intelligence, planning and decisions.

There is a long thread here and the politicians of all parties know it leads into the forest ....

For example, much can be read in a single word "... McKinsey found that only 15 minutes was on the "physical care" of patients while the remaining 10 minutes went on "psychosocial" care, such as talking to patients." I hope that 'only' does not suggest that talking to patients is 2nd best, even though basic nursing care is the factor in the news regarding public perception of the quality of nursing care. This is a constant problem as we move to outcomes. Are we going to have patients saying - "The physical care was excellent, but I felt like I was in a religious retreat. Nobody hardly spoke, explained anything." Patient education, self care, staying well, the effective use of medication and treatment ... is predicated on psychosocial engagement.

What is also very troubling is that cost savings might mean detrimental changes in the skill-mix; the ratio of qualified to health care assistant staff. Some of the best 'natural' nurses I have worked with and work with today are dedicated HCAs. They have a major role and contribution to make, but if safety gains are to be maintained and improved upon then 'safe' skill-mix is critical.

Given the present demographic, 'nurses' are not new to cuts. In the public sector cuts are part of that perpetual motion I mentioned at the start. What frustrates is working on the holistic care mosaic to produce something that is safe, effective, quality care; then as we come to finally add the threads - clinical supervision, PDP, health IT, outcome measures, public engagement we have to unravel and start again.

Image source used with permission and thanks: D L Ennis. Visual Thoughts http://dlennis.wordpress.com/

Balanced Care: Safe Landings and Recovery

In health and social care patient, family and the health care team are united in what is constantly described as a journey. Sometimes there are several, care pathways into territories unknown.

Unknown?

Well yes, if care delivery is personalised (who are we to assume ...?); and yes again even if the patient - the individual concerned is an 'expert' in their condition.

Apart from the metaphysics of life's journey our physical environment can present dangers and yet fewer and fewer corners are truly  unknown. We leave it to astronauts (and oceanographers) to adventure on our behalf. Prior to the Apollo missions it was essential to confirm the nature, solidity of the lunar surface. Would a spacecraft sink and possibly tilt to the extent that return to lunar orbit and Home was impossible?

The Apollo Lunar Module's four legs provided support for a safe landing and take off. A base in every sense.

In health and social care the health career model can provide a base and re-assurance too. Each of the four care domains allied with knowledge and skills - holistic competence - can bring about a successful mission: however the crew and 'success' are defined.

Image source and original text below from:
http://www.robertaonthearts.com/id763.html
Cartier Replica of a Lunar Module
Three individual 18-karat-gold models of the American lunar module were made in 1969 by the jeweler Cartier of Paris on behalf of the French newspaper Le Figaro and presented to the three Apollo 11 astronauts during their post-flight tour in Paris. This model was presented to astronaut Michael Collins.
Image ©Nick Welsh/Cartier Collection 2006

New WHO Quality Toolkit - 'Take ii"

Further to last months post, I've worried at times about the axes of Hodges' model and their status and function. Can I let the axis stand for itself?

INDIVIDUAL

|

|

|

GROUP

Do I expand (explode) the conceptual labels?

self - INDIVIDUAL - person

|

|

|

relationship - family - GROUP - community - population

There seems to be an asymmetry, when you traverse the axis - and its horizontal counterpart; from wherever you start. Perhaps, I worry too much as if the axis was regular then the generic property of the model overall would be diminished. Is this an axis at all?

The website for the Quality Toolkit at: https://qualityhealthservices.who.int/quality-toolkit

- explains the toolkit's scope that includes:

"This new online resource is a user-friendly toolkit to support action on improving the quality of health services at every level of the health system, from national and district to facility and community levels."

I have only scratched the surface here and hope to revisit again - in more detail. Please see below for reflections on the levels by which the toolkit can support action to improve the quality of health services. I have tried to suggest proximity and distance between the SOCIOLOGICAL and POLITICAL (policy). Perhaps, what is a 'clinic' has a name, that it is known by - a key part of the community. The community is closer to the people - to the would-be users of the facility. You can appreciate(?) here the challenge of getting the local community involved in their services. What is 'NATIONAL' should not be remote. Can people compare and contrast with what they are offered? 

 

On the website I note there are video presentations also. The prospect of regular updates for the toolkit is also welcome.

INDIVIDUAL

|

 INTERPERSONAL    :     SCIENCES               

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

SOCIOLOGY  :   POLITICAL 

|

GROUP

psychological access 'My' clinic Trust, I feel safe) (feeling safe) Tell others - my experience..	physical access clinic (appearance, facilities, safety) controlled environment (cleanliness, sterile.., or more social)
'the centre' COMMUNITY DISTRICT national	facility (policy translation / coherence?) community district NATIONAL

Original source: Jules Storr, Independent Consultant, S3 Global & working with WHO as part of the Quality Toolkit development team - via HIFA

Previously: New WHO Quality Toolkit

'Take II'? Quality means getting it right first time (even as you persist in what you are doing - your aspirations and quality improvement). Vitally, this means you, the team make a positive impression for the person, the individual, client .. carer, group. 

If they need to - they will recognise their own ability, knowledge, follow advice, they will come back, they leave not to return soon as they can now self-care and care for others in their home, community ...

 Please note: This post and that previous is not intended to denote endorsement of Hodges' model.