'System 1 and 2 Modes of Thinking' in Hodges' model

 System 1 - 

"operates automatically and quickly,
with little or no effort and no sense of voluntary control. 

 System 2 - 

allocates attention to the effortful mental activities that demand it, including complex computations. The operations of System 2 are often associated with the subjective experience of agency, choice, and concentration." pp. 20-21.

"When we think of ourselves, we identify with System 2, the conscious, reasoning self that has beliefs, makes choices, and decides what to think about and what to do. Although System 2 believes itself to be where the action is, the automatic System 1 is the hero of the book. I describe System 1 as effortlessly originating impressions and feelings that are the main sources of the explicit beliefs and deliberate choices of System 2. The automatic operations of System 1 generate surprisingly complex patterns of ideas, but only the slower System 2 can construct thoughts in an orderly series of steps. I also describe circumstances in which System 2 takes over, overruling the freewheeling impulses and associations of System 1. You will be invited to think of the two systems as agents with their individual abilities, limitations and functions." p.21.

 

INDIVIDUAL

|

     INTERPERSONAL    :     SCIENCES               

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

SOCIOLOGY  :   POLITICAL 

|

GROUP

System 2: Brace for the starter gun in a race. Focus attention on the clowns in the circus. Focus on the voice of a particular person in a crowded and noisy room. Look for a woman with white hair. Search memory to identify a surprising sound. Maintain a faster walking speed than is natural for you. Monitor the appropriateness of your behavior in a social situation. Count the occurrences of the letter a in a page of text. Tell someone your phone number. Park in a narrow space (for most people except garage attendants). Compare two washing machines for overall value. Fill out a tax form. Check the validity of a complex logical argument. p.22.

System 1: Detect that one object is more distant than another. Orientate to the source of a sudden sound. Complete the phrase "bread and . . .". Make a "disgust face" when shown a horrible picture. Detect hostility in a voice. Answer to 2 + 2 = ? Read words on large billboards. Drive a car on an empty road. Find a strong move in chess (if you are a chess master). Understand simple sentences. Recognize that a "meek and tidy soul with a passion for detail" resembles an occupational stereotype. p.21.

Kahneman, D. (2011). Thinking, fast and slow. London: Penguin Books.

See also:

https://thedecisionlab.com/reference-guide/philosophy/system-1-and-system-2-thinking

Depression Worskhop: c/o and with thanks to AffecTech

As posted last September I enjoyed an evening at the launch of AffecTech at Lancaster. This post is prompted by a tweet:

AffecTech Design Workshop: Discussion on Cross-disciplinary Methods for Depression Treatment: https://t.co/7xVinrvmWf #wearables #tech #innovation #research #digitalhealth #mentalhealth #depression

— AffecTech (@Affec_Tech) February 16, 2018

I should add that this post is not intended to represent an endorsement by AffecTech but there is an opportunity to reflect and show how Hodges' model can be used.  I contacted the researchers who - in the spirit just mentioned - kindly forwarded higher resolution images. Of course, not being present at the workshop a lot of information is lost. The reference to art is interesting in itself. It is difficult to capture the context of the whole workshop but - as per the tweet - a short article sets the scene:

AffecTech Design Workshop: Discussion on Cross-disciplinary Methods for Depression Treatment

I have provided two examples of Hodges' model mapping the contents of the workshop. The first,  covers Figure 1: Concept maps of depression causes and symptoms. I don't have a key so there may be the thoughts of several individuals - as per the colours and codes on the flipcharts. Some terms are immediately not only cross-disciplinary but multicontextual in terms of their everyday meaning, for example, darkness, falling, stuck-ness, negative spiral (thoughts, actions), imprisonment mentally, physically, and politically due to dependency, financial constraints.

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

Unreachable hope                                     Pain                                           Weight - burdened        Immobility - motivation                   DEPRESSION    Anxiety DESPERATION                                          Stuck                 Darkness    Grief             Falling Insomnia       Negative filter         No hope Nowhere   Negative spiral                             Lack of interest and motivation Internalising rage   Suppressed emotions Anger Not being listened to                  Darkness

Pain Im-mobility  Physical decline Weight Stuck Chained/Locked to go energy imprisonment Darkness

Imprisonment – Social Isolation No support Hiding Loneliness

Imprisonment – Powerlessness? Loss of control

Next, I have examined the text immediately following and mapped this [my emphasis] to the model.

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------- THE SYSTEM --------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

Identified, general state of lack of interest as a main symptom of depression (lack of energy, negative spiral), and as one of the obstacles for technology-based treatment of it. Therapist input: the emotion regulation component of the system should be suggestion-based (promoting novelty in the patient daily routine). system should be able to continuously monitor* (and predict) the user mood should have an appealing and trust-worthy interface from which it can communicate with the user and modifying his/her immediate context. If depressed - the agent engages the user in a discussion in which a range of emotion regulation techniques is proposed to him/her. Includes: (i) modifying environment (light changes, playing music); (ii) recommending activities; (iii) proposing mindfulness exercises; (iv) engaging the user in a discussion; or (v) recommending the user to look for the support of a friend. Further, at the end of each day the user and the agent discuss progress made over recent days, and define small steps that could be taken in the near future.

Requirement for a pro-active intervention system, and engage the user as soon as (or better just a bit before) a critical situation is detected. System should: *real time - 'always on'? provide daily feed-back to the user (giving a sense of incrementally overcoming problems). Low-fidelity prototype of a system that meet these requirements. Composed of two components: (i) wrist-band device worn by the user that monitors the user mood; and (ii) an assistive agent that is responsible for the emotion regulation system component. Working principle of system - wrist-band devices communicates to the agent when the user is in a depressed mood (- use of biosensors)

Should strive to connect the user with his/her close friends.  Emotion regulation techniques - (v) recommending the user to look for the support of a friend (see above).

The above is provided as a 'pause for thought'. I'm no expert on NLP, but I am acutely aware of the power of the words we use. And how what is said to patients, carers can be returned as a sizzling hot potato that may reveal: great foresight in what you have missed; a major lack of understanding of a situation and treatment plan; and (then) as follows a need for urgent educational intervention. In applications such as this - care needs to be taken in when and were particular words are used. 'Treatment' is in the title, but can be a loaded term as understood by the patient, client, carer, or user. People will say, "No it isn't - this is a 'balanced' approach." but herein risks lie.

Services should be non-ageist and yet culturally if you survey treatment and related terms - from a decennial perspective I wonder what you would find? I have patients who refer to Dr Google and will challenge and ask about their care and if not satified seek further opinions - a fresh pair of eyes; and others who are quite institutionalized in respect of passively accepting what is 'prescribed'. This may be reflected in the length of their mental 'health career' and their previous mental health history.

Please note the inclusion of THE SYSTEM above in the axes and domains of Hodges' model. This is non-trivial. 

At the end of the day (and the start of the night - for someone with depression?) what is the system? I'm not being awkward, but the 'system' in research can become a lay-by. As a compound term it is shorthand, but obviously we need to focus on the elements, constituents and what glues the system together: coherence. As an example, how often in IT project are 'Requirements' the sought after token that signifies "We are on the right track!"? The focus from the above is laudable being clearly person- patient-centred. Is there more that can be said about the system and requirements in the social and political domains? Is there a way also for the agent to figure higher up the design ecosystem (hierarchy)? This is no doubt were the hard work matters - theory, practice - the thesis!

Given the complexity of the (design, care, technical, global...) problems we face I do believe that Hodges' model may serve a purpose in helping to sustain, or ‘recover’ the context – of a situation. This is the purpose of stories of course. The aim of AffecTech's project here is no less than detecting a critical situation. Perhaps this is the truth of 'integrated health records' from wrist device, to agent, patient's record and health services'? It is brilliant to see such initiatives getting underway they are the future....

 (I may add to this post in coming days - weeks.)

With thanks to Alan Cole and Andrea Patane of AffecTech at Lancaster University.

Learning Health Systems: Volume 8, Issue 1 - January 2024

Learning Health Systems is an Open Access journal.

Volume 8, Issue 1 (January 2024)

All articles shown below are freely available and downloadable.

COMMENTARY

Socio‐technical infrastructure for a learning health system

 

Charles P. Friedman, Edwin A. Lomotan, Joshua E. Richardson, Jennifer L. Ridgeway

LEARNING FROM DATA

Privacy‐preserving record linkage across disparate institutions and datasets to enable a learning health system: The national COVID cohort collaborative (N3C) experience

 

Umberto Tachinardi, Shaun J. Grannis, Sam G. Michael, Leonie Misquitta, Jayme Dahlin, Usman Sheikh, Abel Kho, Jasmin Phua, Sara S. Rogovin, Benjamin Amor, Maya Choudhury, Philip Sparks, Amin Mannaa, Saad Ljazouli, Joel Saltz, Fred Prior, Ahmen Baghal, Kenneth Gersing, Peter J. Embi

RESEARCH REPORTS

Analysis of FRAME data (A‐FRAME): An analytic approach to assess the impact of adaptations on health services interventions and evaluations

 

Heather Z. Mui, Cati G. Brown-Johnson, Erika A. Saliba-Gustafsson, Anna Sophia Lessios, Mae Verano, Rachel Siden, Laura M. Holdsworth

 

Automated generation of comparator patients in the electronic medical record

 

Joseph Rigdon, Brian Ostasiewski, Kamah Woelfel, Kimberly D. Wiseman, Tim Hetherington, Stephen Downs, Marc Kowalkowski

 

Stakeholder perspectives on data sharing from pragmatic clinical trials: Unanticipated challenges for meeting emerging requirements

 

Stephanie R. Morain, Juli Bollinger, Kevin Weinfurt, Jeremy Sugarman

 

Learning healthcare systems in cardiology: A qualitative interview study on ethical dilemmas of a learning healthcare system

 

Sara Laurijssen, Rieke van der Graaf, Ewoud Schuit, Melina den Haan, Wouter van Dijk, Rolf Groenwold, Saskia le Sessie, Diederick Grobbee, Martine de Vries

 

Frameworks, guidelines, and tools to develop a learning health system for Indigenous health: An environmental scan for Canada

 

Emma Rice, Angela Mashford-Pringle, Jinfan Qiang, Lynn Henderson, Tammy MacLean, Justin Rhoden, Abigail Simms, Sterling Stutz

 

Predictive modeling for infectious diarrheal disease in pediatric populations: A systematic review

 

Billy Ogwel, Vincent Mzazi, Bryan O. Nyawanda, Gabriel Otieno, Richard Omore

TECHNICAL REPORT

Learning health system benefits: Development and initial validation of a framework

 

Lisa C. Welch, Sarah K. Brewer, Titus Schleyer, Denise Daudelin, Rechelle Paranal, Joe D. Hunt, Ann M. Dozier, Anna Perry, Alyssa B. Cabrera, Cheryl L. Gatto

BRIEF REPORTS

Exploring nationwide policy interventions to control COVID‐19 from the perspective of the rapid learning health system approach

 

Ayat Ahmadi, Leila Doshmangir, Reza Majdzadeh

 

Developing LHS scholars’ competency around reducing burnout and moral injury

 

Sirin Yilmaz, Michele LeClaire, Abbie Begnaud, Warren McKinney, Kasey R. Boehmer, Cory Schaffhausen, Mark Linzer

 

Assessment of learning health system science competency in the equity and justice domain

 

Patricia D. Franklin, Denise Drane

EXPERIENCE REPORTS

Training the next generation of delivery science researchers: 10‐year experience of a post‐doctoral research fellowship program within an integrated care system

 

Richard W Grant, Julie A Schmittdiel, Vincent X Liu, Karen R Estacio, Yi-Fen Irene Chen, Tracy A Lieu

 

Implementing the learning health system paradigm within academic health centers

 

Douglas Easterling, Anna Perry, David Miller

 

Learning from an equitable, data‐informed response to COVID‐19: Translating knowledge into future action and preparation

 

Morgen Stanzler, Johanna Figueroa, Andrew F. Beck, Marianne E. McPherson, Steve Miff, Heidi Penix, Jessica Little, Bhargavi Sampath, Pierre Barker, David M. Hartley

 

Conceptualizing and redefining successful patient engagement in patient advisory councils in learning health networks

 

Madeleine Huwe, Becky Woolf, Jennie David, Michael Seid, Shehzad Saeed, Peter Margolis, ImproveCareNow Pediatric IBD Learning Health System 

COMMENTARIES

Toward a common standard for data and specimen provenance in life sciences

 

Rudolf Wittner, Petr Holub, Cecilia Mascia, Francesca Frexia, Heimo Müller, Markus Plass, Clare Allocca, Fay Betsou, Tony Burdett, Ibon Cancio, Adriane Chapman, Martin Chapman, Mélanie Courtot, Vasa Curcin, Johann Eder, Mark Elliot, Katrina Exter, Carole Goble, Martin Golebiewski, Bron Kisler, Andreas Kremer, Simone Leo, Sheng Lin-Gibson, Anna Marsano, Marco Mattavelli, Josh Moore, Hiroki Nakae, Isabelle Perseil, Ayat Salman, James Sluka, Stian Soiland-Reyes, Caterina Strambio-De-Castillia, Michael Sussman, Jason R. Swedlow, Kurt Zatloukal, Jörg Geiger

 

Can we identify the prevalence of perinatal mental health using routinely collected health data?: A review of publicly available perinatal mental health data sources in England

 

Sarah Masefield, Kathryn Willan, Zoe Darwin, Sarah Blower, Chandani Nekitsing, Josie Dickerson

 

My source: Email request by -

Kathleen Young
Editorial Assistant, Learning Health Systems journal
Victor Vaughan
1111 East Catherine Street
Ann Arbor, MI 48109

Book Review: [ii] Health System Redesign - How to Make Health Care Person-Centered, Equitable, and Sustainable

Part 1 gets straight to the matter of "challenging the orthodoxy" with a two page introduction to complexity and health. Part 1 covers:

• systems sciences
• visualization of complex systems (Capra's vortex metaphor)
• understanding the co-existence of different degrees of complexity and their dynamics within complex adaptive organisations based on Kurtz and Snowden's Cynefin model.
• health as a "complex adaptive experiential state"

All four points here are very pertinent to where we are in health and healthcare (the book rightly stresses this differentiation) and current and ongoing 21st century issues. The use of Capra helps to distinguish scale and the levels inevitably existent, experienced, and described in health and healthcare systems.

If you are familiar with Hodges' model and the Cynefin model, then the answer is yes - seeing the Cynefin model did make me hoot. (I remember Dave Snowden's work from Plaxo and a presentation he did in Lancaster back in 2007). More importantly, part 1 introduces where the focus needs to be to facilitate change; on the core driver of the system, the system's long-term direction, a specific system view and the need for a solid grounding in theoretical and applied approaches. This is were the visual tools and producing a view - perspective are so important. Chapter 2 contrasts the simple scientific world view and the complex scientific. The reader is asked to consider numerous background points, from the colloquial meaning of complex/complexity to the scientific. How do the words 'complex' and 'complicated' differ? At small scale the result is greater certainty BUT loss of context, while at the large scale we find greater uncertainty AND loss of detail.

Figure 2.3 shows the key features of complex systems (also indicating the dynamics - '+' '-'):

• System boundaries
• Interconnectedness
• Feedback
• Impact of starting (initial) condition

Some of the figures point to their means of creation "The essence of systems thinking" (Figure 2.4) produced through Insightmaker. Sturmberg's seeks to ground the discussion too by reference to the everyday. Table 2.1 runs through how systems can be related to the experience of a 'Long day at work'. Addenda are put to immediate effect with a reference to a map of the history of complexity science; the philosophy of complex adaptive systems; and the complexity and difficult questions.

As already suggested Chapter 3 on the visualisation of complex adaptive systems had my attention. The vortex metaphor (Capra) seems trite on first encounter, but it works.* The four different ways to map a system:

1. Systems map
2. Influence map
3. Multiple case diagram
4. Sign graph diagram

are quite important as if you can take the explanations onboard you really will be on the way to fully understanding and utilising theoretical and applied approaches. The learning here is allied with understanding common system dynamic behaviours which are also illustrated and explained. Figure 3.4 shows the Cynefin framework, which is still in my head. The Cynefin model deals with the continua of:

• uncertain - certain
• non-linear - linear

• Contrasts - Learning and Teaching
• and four quadrants that combine what is complex, knowable or complicated, chaos, and known or obvious (simple). The three references here span 1996-2003.

At chapter 4 - I was worried - 'Defining Health' (now there's a task) but this is also interesting, rewarding and well placed. Core notions of health are tabled (4.1) from 1911 to 2007. Health is distinguished from dis-ease. I must follow up the footnote on p.59 Marja Jylhä and her framework of self-perception of health. 

The illustrations on pp.60-61 are frustrating.

Very!

Not because they shouldn't be there, but because they are a gift that remain (as far as I am aware) unrealised in respect of those of us working in the humanities. We still lack the visualisation tools that we need.

If I mention Figure 4.1 "The somato-psycho-socio-semiotic model of health" you will get the drift and overlap with Hodges' model. There is more with 4.2 on Attractors in Health and Illness and the system dynamics of health. The political attractor is missing (and its 'gravitational' impact) in this rendering, but the barriers to progress are also raised at the book's end. Given the topic of health, the text is not science light, with the physiology of health and disease also used to explain points, so we have, gene networks, the autonomic nervous system, the hypothalamic-pituitary-adrenal axis and bioenergetics in the mitochondrion. While not in-depth the potential application across external factors-personal experiences and internal mechanisms are demonstrated. The role of the patient, public and carers are central today and realised to various degree in theory, practice, management and policy. Self-rated health is briefly mentioned and with community health and health services utilisation this closes part 1.

More to follow...

Sturmberg JP. Health System Redesign. How to Make Health Care Person-Centered, Equitable, and Sustainable. Cham, Switzerland: Springer; 2018.

See also first part...

Book Review: [iii] Health System Redesign - Part 2

In part 2 from chapter 5 the focus is "Best Adapted" Health System. Such a system simultaneously addresses person-centredness, equity and sustainability. The healthcare system is one of many subsystems of a complex adapted health system, comprised of primary, secondary and tertiary care. Quaternary prevention may deserve mention? The quaternary approach being sympathetic and resonating with the book's aims as a whole (scope: humanistic - mechanistic and sustainability) .

Chapter 5 uses the Vortex model to represent the vision of a seamlessly integrated complex adapted health system from that which so often exists. The graphics are small but there is a url (Figure 5.1). Several avenues of continuity and links to part 1 are provided, disease, the purposes and goals of existing health systems versus the new vision and the values and need to disambiguate between patient needs and wants. This calls for definitions which are also provided; to logically lead to underlying philosophies which are extended in the addenda.

Chapter 6 prepares the reader for some real world examples to follow. I have long found discussion of scale fascinating. The levels here extend across:

• Macro
• Meso
• Micro
• Nano

"Food regulation" is rendered as an influence diagram showing the various agents and their operations. Copious tables shed light in the four levels. The real world examples in chapter 7 are geographically, Kenya and Brazil concerned with AIDS and the NUKA primary care system in Washington (USA). Sturmberg contrasts the possibly theoretical emphasis of the previous two chapters with this more practical focus. The visualisation methods vortex and Cynefin models are well used here. The case studies help to reveal different degrees of complexity while also showing what they have in common.

You cannot move in social media without reading or hearing about leaders and leadership. Chapter 8 is not paying lip-service to this cultural preoccupation, but marries how can we better understand what is unpredictable. Sturmberg explains VUCA, that is, volatility, uncertainty, complexity and ambiguity; wicked problems and how we can use VUKA and transform these challenges into understanding for learning and transfer of knowledge. Again the book carries the content forward, combining four learning frameworks to shift mindsets and world views through use of the Cynefin framework.

In the management of system constraints a multidiscipinary (multi-domain) approach is used, as in leadership involves psychological work. To better appreciate leadership, leaders are contrasted with managers (Table 8.2, p.139). An example of contrast is also used characterising organisations as Banyans (which expand their own empires) and Dandelions (which while prolific allow others to thrive). The references range in chapter 8 from 1958-2017 - Argyris, Mintzberg, Polyani and Schön. The addenda closing chapter 8 and part 2 are once again philosophical - "History of Reductionism" and very much add to the text.

There's an important quote on page 140:

"It is the common cause of an organisation that defines its identity and must reside in the heads and hearts of its members. Thus, in the absence of an externalised bureaucratic structure, it becomes more important to have an internalised cognitive structure of what the organisation stands for and where it intends to go - in short, a clear sense of the organisation's identity. A sense of identity serves as a rudder for navigating difficult waters.'

I think 'identity' for the individual (micro) and organisation (meso-macro) levels could be emphasised more and should be indexed. Parts 3 & 4 follows.

Sturmberg JP. Health System Redesign. How to Make Health Care Person-Centered, Equitable, and Sustainable. Cham, Switzerland: Springer; 2018.

See also:

Book Review: [i]

Book Review: [ii]

Book Review: [i] Health System Redesign - How to Make Health Care Person-Centered, Equitable, and Sustainable

Health System Redesign

The 'summer reading' is almost complete (p.245/290) and described as such due to it being a review and a specific deadline is not helpful. (You may have noticed with Drupal and the new site!). Fortuitously, starting the book coincided with my attending the UKSS conference in Portsmouth. The exposure to systems and complexity - as in complexity science was welcome. I would really like to write a paper on Hodges' model and complexity and this book would be a primary reference.

The foreword is by the President of the Lown Institute, this is a think-tank "advocating a radically better and uniquely American health system that overturns high-cost, low-value care." Sturmberg provides the means for this over-turning whilst beforehand explaining what is happening in the health system and health care systems worldwide. There is a difference, as we must change mindsets and facilitate the health system reducing the impact, dependence and expense of existing health care systems. What we have is no longer sustainable.

Even in Sturmberg's preface I can see why this book through its title had an instant appeal to me and should do so to others in the health, social care, policy and educational communities.

The book addresses three key themes:

1. Understanding complexity—what are complexity sciences, and how does complexity thinking shape our understanding of health
2. Envisioning a “best adapted” health system
3. Achieving a person-centred, equitable and sustainable health system

The promised references follow the chapters (as expected!), but often with addenda that provide more background, insight and further reading if needed. Page 2 provides the first of many figures throughout the book, as with copious footnotes. Some people and publishers find footnotes untidy or contributing noise. I found these informative, pointing in some instance to video resources and copies of diagrams that are too detailed for a book. Inclusion still conveys some meaning given the subject matter of complexity and scale through the levels of nano, micro, meso and macro.

The book is clearly laid out, chapter 1 precedes Part 1 to set the context and agenda. Sturmberg explains this is not a theory book, but the explanations are progressive and a good foundation for further study (that must follow). Some of the challenges in teaching and learning systems thinking and health(care) systems redesign are discussed, as students are bound to encounter them not only in the literature, but in many of the assumptions that they are being socialised into in practice. A good example, is Table 1.1 Disambiguation of systems complexity (p.5). Like the use of figures, tables are liberally but effectively distributed throughout to reinforce the discussion. I like the way that systems thinking tools are set out in Table 1.2 across three pages. The tables and figures are not just page-fillers though, but sources to return to.

The differing sections that apply systems thinking are set with the implications for health care. As already mentioned some of the figures are colour reproductions and suffer due to the print size. To compensate the original source is usually provided (Addendum 2, Obamacare Health System Chart is a prime example that also time places pressure on any text). This works well as the author grapples to illustrate scale from the individual to the organisational level, industrial and processes and policy makers.

I know a review is about the book, but in this case especially I cannot but help see how this topic supports and validates (imho!) my own work and interests. Page 9 confirms how h2cm not only incorporates "design thinking" as it can readily combine the sciences and the arts (as in various blog posts). As I have stated (for 30 years) the POLITICAL domain in Hodges' model is crucial in the 21st century. So, even as I reach Part 1 for this review, the importance of global health; policy, organisations, public engagement are stressed if change is to follow. Many sections have a short introduction that ends with questions for readers to reflect on their own health systems experiences. As a summer reading project through to part 1 I was very pleased to have an 'ice-cream' of my favourite flavour that was going to run and run...

Sturmberg JP. Health System Redesign. How to Make Health Care Person-Centered, Equitable, and Sustainable. Cham, Switzerland: Springer; 2018.

More to follow three - four posts in total?

Pre-Publication Discount: Nursing and Clinical Informatics - Socio-Technical Approaches

Take Advantage of the Pre-Publication Discount by Ordering this Book Today!


Nursing and Clinical Informatics: Socio-Technical Approaches

Edited By: Bettina Staudinger, University for Health Sciences, Medical Informatics and Technology, Austria; Victoria Höß, University for Health Sciences, Medical Informatics and Technology, Austria; Herwig Ostermann, University for Health Sciences, Medical Informatics and Technology, Austria


Description:
The field of nursing informatics is one of the fastest growing areas of medical informatics. As the industry grows, so does the need for obtaining the most recent, up-to-date research in this significant field of study.

Nursing and Clinical Informatics: Socio-Technical Approaches gives a general overview of the current state of nursing informatics paying particular attention to its social, socio-technical, and political aspects to further research and development projects. A unique international comparative work, this book covers the core areas of nursing informatics with a technical and functional respect and portrays them in their proper context.

Table of Contents:

Chapter I: A Treatise on Rural Public Health Nursing

Wanda Sneed, Tarleton State University, USA The objective of this chapter is to promote public health nursing and community health nursing’s role in the new care delivery patterns, with predictive and preventative care models for populations. This entry will broaden the range of information available for informaticists, as their role expands in the new healthcare arena. Articulation with nursing informatics and the “quality chasm” crossings in U. S. healthcare will assist the informaticists with search and retrieval activities. All players in the healthcare arena will continue to be involved, but probably with a more rational policy-making role.

Chapter II: Assessment in a Computer-Based Nursing Documentation

Elfriede Fitz, University for Health Sciences, Austria
Daniela Deufert, University for Health Sciences, Austria
Johannes, Hilbe, University for Health Sciences, Austria
Christa Them, University for Health Sciences, Austria Experience in nursing practice shows that there are still problems with assessment in computer-based nursing documentation. In addition to nursing documentation, an assessment instrument that captures the needs for care must also be integrated. This chapter describes different Nursing Assessment Instruments and the advantages of Computer-Based Nursing Process Documentation by using quality criteria for assessment instruments such as validity, sensitivity, specificity, reliability, practicability, and the appropriateness of the instrument. Quality criteria for computer-based systems are basically software ergonomic aspects and therefore not part of this study. Each country should choose for itself those specific assessment instruments that capture the needs for care of their clients. The data presented make it possible that facilities are compared (also in regard of reliable cost estimates).

Chapter III: Clinical Decision Support Systems in Nursing

Dawn Dowding, University of York, UK
Rebecca Randell, City University, UK
Natasha Mitchell, University of York, UK
Rebecca Foster, School of Health Sciences at the University of Southampton, UK
Valerie Lattimer, School of Health Sciences at the University of Southampton, UK
Carl Thompson, University of York, UK Increasingly, new and extended roles and responsibilities for nurses are being supported through the introduction of clinical decision support systems (CDSS). This chapter provides an overview of research on nurses’ use of CDSS, considers the impact of CDSS on nurse decision making and patient outcomes, and explores the socio-technical factors that impact the use of CDSS. The chapter presents the results of a multi-site case study that explored how CDSS are used by nurses in practice in a range of contexts. The study reveals that how a system is used and may vary considerably from the original intentions of the system designer.

Chapter IV: Culturally Sensitive Healthcare for Newcomer Immigrants

Jerono Rotich, North Carolina Agricultural & Technical State University, USA This chapter will give an overview of the healthcare-related challenges that most newcomer immigrants and refugees encounter as they acculturate into their new environments in Western countries. It will highlight practical tips that can: a) enhance the caregiver and patient relationships across cultures and across continents; b) enhance culturally sensitive healthcare services; and c) help to create culturally inviting healthcare environments. It is also evident that, although these newcomers enrich their new nations with their diverse backgrounds, language, and cultural differences, each continues to pose formidable obstacles to their health, healthcare providers, and the health system in general. While the patients and providers realize the effects of immigration on the quality and access to healthcare, they seem to be overwhelmed by the barriers.

Chapter V: Mobile Technology in a Developing Context: Impacts and Directions for Nursing

Pammla Petrucka, University of Saskatchewan, Canada
Sandra Bassendowski, University of Saskatchewan, Canada
Thomas F. James, Apogia Networks, Ltd. , Canada
Hazel Roberts, Government of St. Kitts-Nevis, Ministry of Health, Canada
June Anonson, University of Saskatchewan, Canada This chapter presents the imperatives of mobile technologies in the healthcare. It presents the contextual overview in development of the diffusion, penetration, and uptake of health-related mobile technologies. A consideration of the roles and responsibilities of the diaspora in the embracing of information and communication technologies is emphasized. Key examples of mobile technologies in development to increase understanding and demonstrate promising practices in this emergent field are given.

Chapter VI: Nursing Documentation in a Mature EHR System

Kenric W. Hammond, VA Puget Sound Health Care System, USA
Charlene R. Weir, University of Utah, USA
Efthimis Efthimiadis, University of Washington Information School, USA Computerized patient care documentation (CPD) is a vital part of a Patient Care Information System (PCIS). Studying CPD in a well-established PCIS is useful because problems of system adoption and start-up do not interfere with observations. Factors interfering with optimal nursing use of CPD are particularly challenging and of great concern, given today’s shortage of nursing manpower. The chapter describes problems and advantages of CPD usage identified by nurses in a series of research interviews. It is shown that explicit consideration of nursing workflow constraints and communication processes is necessary for development of effective nursing documentation systems. Some findings point to a PCIS reconfiguration strategy that is feasible in the short term. Other findings suggest the value of considering mobile and team-oriented technologies in future versions of the PCIS.

Chapter VII: Nurses and Telehealth: Current Practice and Future Trends

Sisira Edirippulige, University of Queensland, Australia
Anthony C. Smith, University of Queensland, Australia
Mark Bensink, University of Queensland, Australia
Nigel Armfield, University of Queensland, Australia
Richard Wootton, University of Queensland, Australia Home telehealth, the use of information and communication technologies to deliver and support healthcare directly to the home, is emerging as an important application for nurses. This chapter provides an overview of home telehealth and how it may be applied to the practical challenges nurses face everyday. We provide a summary of the evidence available to support its use in specific areas and a guide for those thinking of implementing telehealth in their own practice. The future of home telehealth lies in carefully considered and designed research, ongoing education, and training and a multidisciplinary approach.

Chapter VIII: Successful Online Teaching and Learning Strategies

Mary D. Oriol, Loyola University New Orleans, USA
Gail Tumulty, Loyola University New Orleans, USA This chapter presents a theoretical framework and research base for the successful transition of an established Master of Science in Nursing program from that of traditional classroom delivery to one that is Web-based with no geographic limitations to students. The application of socio-technical systems theory to facilitate creation of a positive learning environment for future nurse leaders is described. Use of social processes and application of technology to optimize learning is explained and the latest research on content presentation and student engagement in an e-learning environment are presented. The chapter gives an understanding of the competencies necessary for students and faculty to be successful in online education.

Chapter IX: Shaping Funding Policy for Nursing Services

Virginia Plummer, Monash University, Australia Concerning nursing resource allocation health service executives have different views about whether systems based on ratios or those based on patient dependency are more accurate. This chapter reports on a statistical analysis of almost 2 million hours of nursing data provided by 22 acute care public and private hospitals in Australia, New Zealand and Thailand. To evaluate both ways an informatics system was used which has the capacity to simultaneously measure nurse patient ratios and nursing workloads by a dependency method of nursing hours per patient day. The results showed that it predicts actual direct nursing care requirements with greater accuracy than ratios for all hospital and patient types, facilitating better allocation of nursing resources and demonstrating that the cost of nursing care would be less for hospitals using that system than for ratios.

Chapter X: Simulations to Assess Medication Administration Systems

Elizabeth M. Borycki, University of Victoria, Canada
Andre W. Kushniruk, University of Victoria, Canada
Shigeki Kuwata, Tottori University Hospital, Japan
Hiromi Watanabe, Tottori University Hospital, Japan A range of new technologies/information systems are being implemented in clinical settings in order to reduce errors associated with the medication administration process. Simulation methods can be used to assess the impact of integrating new technology/information systems into the nurses’ work environment prior to full-scale implementation of a health technology/information system. Simulations as an evaluative tool emerged from a direct need to assess unintended and intended consequences of health information systems upon nurses’ work before systems are fully implemented. Nurse information use of simulations to assess and test health technologies/information systems will allow nurses to determine the impact of a new software and/or hardware upon aspects of nurses’ work before its implementation to allow for appropriate system modifications.

Chapter XI: Socio-Technical Structures, 4Ps and Hodges' model

Peter Jones, NHS Community Mental Health Nursing Older Adults, UK This chapter explores the potential of a conceptual framework – Hodges’ model – both as a socio-technical structure and means to explore such structures of relevance to nursing informatics theory and practice. The model can be applied universally by virtue of its structure and the content which it can encompass. In apprehending this chapter, readers will be able to draw, describe, and explain the scope of Hodges’ model within contemporary healthcare contexts and the wider global issues presented by the 21st century that influence and shape nursing informatics. Critically, the reader will also gain insight into how socio-technical structures can facilitate cross fertilization of clinical and informatics theory and practice; drawing attention to information as a concept that provides a bridge between socio-technical, clinical, and informatics disciplines. The paper will review the socio-technical literature and venture definitions of socio-technical structures related to Hodges’ model and advocate the need for sociopolitical-technical structures. This chapter also proposes the 4Ps as a tool to facilitate reflection upon and the construction of socio-technical structures. The adoption and significance of the hyphenated form as per “socio-technical” will also be explained.

Chapter XII: Strategies for Creating Virtual Learning Communities

Beth Perry Mahler, Athabasca University, Canada
Margaret Edwards, Athabasca University, Canada Teaching nursing online requires teachers to purposefully use strategies that facilitate the development of virtual learning communities. This chapter proposes answers to the question, “How can educators effectively teach the very social discipline of nursing in virtual classrooms?” Specific online teaching strategies including Photovoice, Virtual Reflective Centers, and Conceptual Quilting are explored. The social and socio-technical implications of teaching nursing online are considered. A final section in the chapter describes how these developments in online nursing education are changing the social and pedagogical perspectives of distance learning. Research questions that arise from this exploration are presented.

Chapter XIII: The Impact of Technology in Organizational Communication

Roberta Cuel, University of Trento, Italy
Roberta Ferrario, Laboratory for Applied Ontology (ISTC-CNR), Italy In this chapter a case study is presented, in which the ethnomethodological approach is used to analyze the impact of the implementation of an information system, called Sispes, on organizational communication processes in the residence for elderly Giovanelli (Italy). Sispes is a Web-based platform which sustains communication processes and knowledge management according to a customized workflow management system. Adopting structuration theories in the analysis of the case study, and taking inspiration from the philosophical tradition, especially in epistemology and in the analytic philosophy of law, an innovative perspective is adopted, which specifically acknowledges the role played by the communication processes in shaping both the attitudes of the involved actors and the social reality in which they are immersed. According to this perspective, three types of communication processes are presented, namely the normative, descriptive and constructive approach. These latter are then applied to a concrete case study.

Chapter XIV: The Roles of a Nurse in Telemedical Consultations

Boris A. Kobrinsky, Moscow Research Institute for Paediatrics and Children’s Surgery, Russia
Nikolay V. Matveev, Moscow Research Institute for Paediatrics and Children’s Surgery, Russia Telemedicine, or distant medical consultations using communication via electronic networks, is gradually becoming a standard of medical care delivery in distant areas worldwide, including both the most developed and the developing countries. For instance, in 2007 telemedical centres existed in 55% of the Russian regions (on average, about 4 centres in each region). In most of the cases, nurses are actively involved into organization of various types of distant consultation. Main types of telemedical services include: (1) emergency consultations of patients by telephone (2) telemedical consultations using videoconferences or store-and-forward systems and (3) home telecare systems. Possible roles of nurses in different types of telemedical consultations are discussed.

Chapter XV: The Role of EBM and Nursing Informatics in Rural Australia

Daniel Carbone, University of Melbourne, Australia The purpose of this chapter is to discuss broadly the need for enhanced evidence-based medicine (EBM) by nurses in the context of rural Australia and the role that nursing informatics and an informed strategy could facilitate in making such need a feasible reality. First, the introduction highlights current time gaps between health discoveries and eventual practice and the potential for information technology to positively affect this gap. Then, the need for nurses to take an active role in evidence-based medicine in rural settings is argued. The link between information literacy and evidence medicine is consequently presented and gaps in knowledge regarding nursing informatics training are highlighted. Concluding with the argument that to achieve evidence-based research and eventual use, there needs to be a purposeful health informatics learning strategy that recognises the role of computer and information literacy.

Chapter XVI: Use of Handheld Computers in Nursing Education

Maureen Farrell, University of Ballarat, and RMIT University, Australia The use of mobile technologies in nursing education is rapidly increasing. Handheld computers are the most frequently used of these technologies as they can provide students with information for point of care clinical reference, such as diagnostics, medical terminology, and drug references. Integrating the management and processing of information into clinical practice is an effective learning approach for students and reflects a changing paradigm in nursing education. Traditionally, nursing programs have the tendency to separate the acquisition of academic knowledge from clinical practice, and the process of integrating academic information into the decision-making processes in the clinical area has been difficult for student nurses. This chapter will provide an overview of the use of handheld computers in nursing and medical education, including a brief synopsis of current use in clinical practice. It will discuss the advantages and disadvantages of their use, barriers to implementation and future directions.

Chapter XVII: Using Information Technology in Nursing Education

Elizabeth Rogerson,University of Dundee, UK
Linda Martindale, University of Maryland School of Nursing, USA
Carolyn Waltz, University of Maryland School of Nursing, USA This chapter addresses issues relating to nursing informatics as used and applied in nursing education. This includes the use of information technology (IT) in delivering nursing education, as well as the teaching of IT and informatics skills to prepare nurses for practice. Drivers associated with the development and use of IT in nursing education are discussed, as well as current use of IT in nursing education and practice, including both mainstream and emerging technologies. Lastly some key issues for the future are identified. Internationalism is regarded as a consistent theme in IT development and occurs as a recurring thread throughout this chapter.

Book Review: [iv] Health System Redesign - Part 3 & 4

Part 3 tackles the structure and dynamics of health system organisations. The introduction begins with how we perceive whole and part and teases out levels once again. These have their own concepts and language as we move through layers. This transition between layers means we also have to dispense with, or suspend the detail that a layer gives us - the 'cellular level' for example. Sturmberg describes the properties of layered systems that include, concepts, discovery, interaction and constraints. As is often the case through the book, table 1 (chapter 9) captures a great deal with figure 3 - health system phenomena and different levels of organisation. The final addendum of part 2 posed the questions: what to change?; what to change to?; and, how to cause the change (p.158)? This introduction reminds us of the constant need to consider parts (data) anbd the joining of wholes (wisdom).

Chapter 9 is about modelling, potentially a dense and jargon-ridden subject, but the treatment here retains the book's accessibility, clarity and interest. This chapter is like an answer to a soapbox of mine as it highlights the role and use of spatial modelling and geographic information tools. Admittedly, as clinicians (all disciplines) we cannot be service planners and public (mental) health specialists, but services should have access to such tools. (Teams could have a running list of 3 research questions that can be taken up, revised by students and team members, perhaps allied to CPD and other training/education commitments). Sturmberg gives us: mental health services in Helsinki; childhood obesity in Berlin; Life expectancy in a city and infection risk in Democratic Republic of Congo.

On first picking up the book, the arrangement of the parts with an introduction and the chapter introductions can be a little confusing. But the disorientation is brief. The book has some typos: 'intense' for 'intents' p.171; 'locking' for 'looking' p.179; 'build' for 'built' p.225; 'pleural' for 'plural' p.234; outlined, p.251. (I used to read papers for data definition standards.)

This does not detract from something special in 9.3 modelling system problems. The question is "What ... if..? and a series of scenarios in aged community care: What if -

• We double the number of nursing home beds?
• We double the social care workforce?
• We combine a 50% increase in both the above?

The addenda for chapter 9 are system diagrams and link to chapter 10 very nicely returning to micro, meso and macro levels. I could sketch out the multiple cause and sign graph diagram fig 10.1 for a patient and how deteriorating health results as much from the interdependent variables of his social context as basic physiology (p.197 - another case study).

With a book that can serve as a key reference for Hodges' model - it had to happen (sorry!). Here I have mapped some of the content of Table 10.1 (p.209) to h2cm:

individual

|

INTERPERSONAL : SCIENCES

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

SOCIOLOGY : POLITICAL

|

group

Mental Health	Hip replacement surgery Flu vaccination Multimorbidity management of polypharmacy Intensive Care Unit Managing a second degree burn Protocols - handwashing -
Community care for frail elderly Managing a natural disaster (social impact)	- policy Health financing Nurse unit manager ensuring staff record every patient incident regardless how trivial Surgeon managing theatre team Acute psychiatric Unit Bed management of a hospital (*see below)

This week driving between my community visits, a radio public health notice asked listeners: what is the 2nd most significant cause of cancer after smoking? It begins with 'O' and ends with 'Y'. Chapter 11 concerns obesity at the personal, personal-community, and community-whole society levels. This chapter relies on diagrams-figures, some are difficult to read and with no web reference to go to the detail is lost (figure 11.10). The message is not lost, however; a magnifying glass might help (figure 11.8). 'Obesity' must include the industrial and political dimensions.* 'Food sovereignty' is an important point (p.223). If blockchain technology does prove itself beyond cryptocurrencies could it find an governing application in food system regulation?

Sturmberg anticipates there is/will be resistance and refers to the need:

"to overcome some of the false and unhelpful conceptual dichotomies in the debate about the obesity epidemic"p.227.

What follows then is a need for informed debate and argumentation?

Part IV brings to life the book's subtitle and achieving this goal: Chapter 12 how things ought to be. The introduction here is rich - 6 pages, 16 references mainly tables but informative.

Personomics p.246 is a gift to me and unsurprisingly it is allied with person-centredness. Sturmberg rightly stresses how we need to put the person at the centre of the system. Although referred to constantly - to the point of rhetoric? in the literature, politicval media. In Hodges' model I have stressed how 'work' is involved in achieving person-centredness and being person-centred. In the model the individual needs to 'moved' conceptually, in the first instance to the centre of the model.

With figure 12.2 I'm still sore from the back-flip. I've possibly seen this before, but the version on p.249 is again very meaningful and vital to holistic and integrated care.

https://www.storybasedstrategy.org/the4thbox

I would switch this slightly for h2cm, thus:



EQUITY :: EQUALITY


REALITY :: LIBERATION

The book ends on design and design thinking. H2cm leads inevitably to structure and content and as such care architecture and so design. Here the book is talking 'problem solving strategies' and hence Health System Redesign. Such ambition needs to attend to barriers and once again in 13.4 we consider "what might stand in the way". Even at the end Sturmberg is clarifying and extending definitions: Adam Smith - the Public Good AND the free market; 'social' and 'socialised'. This is not an oversight but helps close a fascinating circle and excellent book.


The 'blurb' as they say refers to the book as a "forward-looking volume" - together with the knowledge here - and crucially the combined wisdom that results - we can make it here-and-now.

I would like to express my many thanks to Prof. Sturmberg and Springer for the review copy.

Sturmberg JP. Health System Redesign. How to Make Health Care Person-Centered, Equitable, and Sustainable. Cham, Switzerland: Springer; 2018.

See also:

Book Review: [i]

Book Review: [ii]

Book Review: [iii]