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The Multicontextual Nature of Health

Keywords: Health Career, Contexts, Conceptual Framework, Care Domains


Citing this page:

Jones, P. (2000) Hodges' Health Career - Care Domains - Model, Multicontextual Nature of Health:

<>, Accessed


Introduction

Mr James Burke

Do you remember the TV programme Connections, written and presented by James Burke? In Connections Mr. Burke makes associations between ideas, inventions, and individuals? This is something people do all the time. No, not necessarily linking ideas, inventions, and individuals, but people, places, events, for reasons of education, entertainment and to enable day-to-day living (survival!).

Mr. Burke must have a framework, a set of ingredients (and researchers!) for his TV programmes. This might comprise: a mix of substances (elements), dates, personalities, motivations, accidents and coincidences. Beyond educational TV media, people must also associate, relate, link many concepts, events, attributes, people and roles.

Healthcare professionals have a plethora of associations that (as with all) must be learned before they can be used. As Benner (1984) and others have shown this learning process, is an essential part of the transition from novice to expert. Doctors are the most obvious in this respect, many years training to connect signs and symptoms with diseases, syndromes and ailments.

Nursing utilizes many disparate sources for theoretical underpinning, being highly eclectic in its knowledge base. Nursing is also situational (isn't everything?) nurses practice in hospitals, out-patient departments, homes, health centres, community mental health centres, schools and very soon if not all ready supermarkets and shopping malls. So if James Burke needs a framework so do nurses and other health care professionals. A framework with the scope to handle their broad knowledge base, plus the varied situations or contexts find themselves in.


HCM and health care contexts

HCM provides an invaluable framework for recalling and recording knowledge and situations. So while Mr. Burke has a framework for making his TV programmes, so nurses and the wider health care team need a framework to support their care programming. Watching Connections reveals, however, that it is not just making connections that is important, Mr. Burke's Connections must serve a purpose, several in fact:

  • follow a narrative path - tell a story (be meaningful);
  • educate;
  • entertain;
  • surprise;
  • be relevant;
  • fit within time constraints;

In health care our frameworks must also be multifunctional (very!):

  • be comprehensive as an aide memoir;
  • be bounded - affording basic apprehension, or complex as necessary;
  • be relevant;
  • help reduce risk;
  • tell the patient's story;
  • fit within time constraints;
  • capture vital information from other professionals;
  • must include carers, family, guardians;
  • support and reinforce the curriculum and practice education;
  • assist in supervision;
  • care evaluation;
  • help support health education & welfare objectives;
  • allow for prioritizing;
  • (in summary!) act as an effective, efficient communication tool.

and more besides...?

Tools that can meet this list of requirements must be fairly special, and Hodges' HCM certainly appears up to the task. Much emphasis is placed in nurse education on the individual (patient's) needs and the patient as a member of a group, whether family, work colleagues or a specific community. Medicine is still engaged in reducing the patient to a series a mechanistic descriptions and systems, often struggling with the subtlety and sensitivity of humanism in communication and wider social concerns. The politics of health care provision is present and the forces acting on the professionals. For example, what price can we attach to the rise of private health care in the UK, and the influx of agency nursing on work patterns and standards of care?

The Health Career Model grid below highlights various concepts represented in 'its' subject domain.

Interpersonal titleinterpersonal icon

So within the interpersonal quadrant you will find faces representing emotions and moods. A guitar, yacht, palette and hammer stand for hobbies, motivation, planning, activity and demonstrable skills. The eye and other senses - perception and ultimately the process of ascribing meaning. A baby and elderly figure express the process of human development, and the cultural pressures on the individual, that may in turn be influenced by gender. Spirituality resides within us as individuals and in religious institutions - in this case the cross - but across all faiths and religious beliefs.

The symbols and hand highlight cognitive abilities, attention, calculation, classical IQ and emotional IQ, educational capacities - learning, recall. The 'cognitive triad' Beck (1979), also resides in this quadrant, beliefs that individuals hold about self, others and the world. What positive and negative experiences has this individual encountered?

Two heads denote communication, moving towards the social quadrant were verbal and non-verbal forms of information come to the fore. What are the individual's capacities for handling information, cognitively and their understanding of the various media used to capture, transform and transfer it?

The linked computers variously stand for human-computer interaction; the social impact and application of ICT; the political and economical ramifications - "access for all", control of information; security and confidentiality. (A computer is not included in the science quadrant due to space limitations, but physical laws and properties of matter are of course crucial to making ICT possible, as exemplified in the OSI specification.)


A selection of concepts icons placed upon Hodges' model grid

caduceus - science iconScience title

Located in the far upper-right of the science-empirical quadrant are the universal constants of time, structure of matter and the highly mechanistic processes we have yet to fully understand. Chemistry and other 'hard' sciences are revealed in the test tubes and Bunsen burner. The bread denotes nutrition, metabolic processes, bodily systems and functions, e.g. digestion, endocrine, elimination, growth, cell regulation and repair. Anatomy and physiology are key knowledge bases here. Physical care and treatments, such as medicines via the staff; investigations and tests. The physical processes involved in memory, still incompletely understood are shown by the elephant.

In this quadrant arise issues that challenge us individually (what do we believe?), culturally and globally. How do we view knowledge? Should knowledge be sought for knowledges' sake? Especially, in the wake of bioterrorism. What will be the impact of genomics and proteomics? What of scientific progress and the state of the biosphere. While science and technology benefits many communities, what of others? What are the effects on distant habitats and life? What does sustainability actually mean (Meppem & Gill, 1998; Wals & Jickling, 2002)? The need to look further than self, material things and technology is addressed by Chiesura & de Groot, (2003). They argue that we need to understand the ways that natural capital is so critical to individual, community and ecological health:

The experience of nature is perceived as beneficial to people’s mental health and psycho/physical equilibrium in general. Ecological, health and heritage functions are the most important services nature generates to human societies. Though essentially immaterial, these functions fulfill crucial human needs and contribute to the sustainable development of human societies. It is, therefore, crucial to identify and assess their values so that they can be better accounted for in environmental and nature management policies. To identify and assess the sociocultural functions of NC, both qualitative and quantitative valuation methods have to be used. Chiesura & de Groot, (2003) p.229.


political icon Political title

Interpreting the remainder of the image in a clockwise manner, we find the worlds of economics, the politico-cultural milieu in which health care must take place. Ecology and care of the biosphere, noted previously, obviously have political ramifications. Provision of services such as, water and energy; welfare, law and order, justice, organisations, policy, bureaucracy and economical factors that directly influence and shape employment conditions and opportunities for all. Also the politics of health: the movement from compliance to empowerment and concordance views of the patient - professional encounter (Feste & Anderson, 1995). The debate about advocacy and who is able to practice this role to meet the needs of older people and children (Waterston, 2002). Mental health law and systems of advocacy, individual rights and respect for those rights, the effects of formal mental health admission, consent, and sensitive matters such as learning disability and rights, quality of life and controversial treatments such as electroconvulsive therapy (ECT). Information from the other three domains is rendered visible or invisible in this particular quadrant. The triad of demand, supply and outcomes land on the desks of those with the power to information manage. Quality measures and feedback should be a proactive, ongoing aspect of service delivery - not just a political sound bite. What targets should be set for doctors, nurses, social workers and other staff? Governmental targets can quickly become a political 'game' , initially played over the heads of patients, but whose effects finally make them visible to all.


Sociology titlesocial icon

Employment spans the social and political hence the image denoting spanner, female construction worker, and disabled. The 'sold' sign attempts to stand for social mobility, the house for the notion of home, recognizing that this convention does not apply globally and for all peoples. This icon may also capture the concept of family and the various social roles and structures found within, this would include one-parent families and other relationships. Shaking hands also illustrates non-familial relationships people also engage in. The graduate denotes the educational system, which - with the family - is also a key socialization process.

Social - relationships illustration

A non-smoking sign borders the social and political quadrants, stressing the ongoing need for health education and promotion. Interestingly, for an area that will be critical in the 21st millennium, in placing health education its locus (in this representation) lies at the centre of the HCM grid.

The HCM and the exercise conducted above highlights how varied and intricate the contexts of health (life!) can be. Berg & Goorman (1999) stress that medical information must be viewed sociologically. They propose the following law:

'Information should be conceptualized as always entangled with the context of its production. The disentangling of information from its production context is possible, but that entails work. We propose the following `law of medical information':

the further information has to be able to circulate (i.e. the more diverse contexts it has to be usable in), the more work is required to disentangle the information from the context of its production.'

ruler

The above HCM example and descriptions of each quadrant, provides a broad rendering of the HCM in action. The HCM's potential, however, extends to specific applications, used in standalone or combination. Possibilities are:

FRAMEWORK APPLICATION FACTORS
PURELY CONCEPTUAL LEVEL

simple

complex

single concept

multiple disciplines (quadrants)

single concept

single discipline

PROBLEM LEVEL

actual

potential
severity

PROGRESS

(TEMPORAL)

expected

actual
variance

CONTEXTUAL

location (physical)
'owner' (surgery - Dr.)
rapport - first visit or established relationship
purposes - screening, education, treatment, counselling...
education
research
management

PERSPECTIVE

patient/client
carer/relative
nurse/other health care practitioner/advocate
managers
policy makers

The examples a - h outlined graphically below are merely suggestive, the variations are legion?

a)
Here the assessor identifies different care problems within the subject domains. Where the HCM has been used this is the most common form of application; identifying the range of problems helps to determine a care plan, care package, or care programme. The assessor may stop and note a lack of problems in the sociological quadrant, for example, which prompts the question: "Have I missed anything?"

The usual application of Brian's Health Career Model

b)
In this example one concept is related across the subject disciplines. This does not mean that all concepts can be treated in this way. This particular application is expanded below. It is this ability, a characteristic of expert practitioners that researchers must take into account, in their attempts to reduce variables and resort to tacit knowledge, that expert workers often employ.

Relating one care concept / problem across all subject disciplines
c)
An in-depth appraisal can be made focusing on a specific quadrant. This may be useful in case studies, and case conferences, with specific quadrants the focus for presentations. Social workers may(!) focus in detail on the political aspects of a case - mental health legislation; child protection; the political aspects of relationships, power, autonomy, self-determinism, management of finances. While family therapy teams consider in detail psychological, sociological and political aspects. Other tools will be used - a genogram to hypothesize and ultimately assist a family. The process of engaging a family for therapy can also show holistic effects as domains mediate with each other.
an in-depth analysis of one subject domain, perhaps for education, case studies.
d)
A problem-oriented view can highlight the relation of actual and potential problems within or across subject quadrants. Resources will always be scarce, so to improve efficiency and effectiveness templates could be created for specific care situations, as is already common practice in health care recording, for example via integrated care pathways.

exploring actual and potential problems
e)
The priority of problems can be readily recorded, as simply as a number; or using colour; sound or other visual cues. (It is essential of course to ensure that people know what is meant by '1' as opposed to '5'.) Why do this? In the UK and no doubt elsewhere the use of agency staff is more common, this can have an impact on continuity of care? Qualified staff new to a clinical area, naturally hone in on 'critical' patients, and hence 'critical' information. Can other support tools help?
determining a view of priorities

f)
Although space is limited here, this basic diagram shows how several perspectives of a care situation can be recorded: Patient; Carer and Nurse. Whilst linking these can make for pretty patterns(?), an extension of this theme and germane to quality of care is a record of the present and were each agent feels they are moving. Will it be easy to reconcile these views? What are the resource implications?
Anticipating future trends this could potentially include self-assessment, and a solutions focus can be as readily represented as problem oriented one.

f) and g) can be combined with the specific goal of risk management, which was of course one of Brian's initial objectives - how to ensure a comprehensive assessment. Taking due notice and recording of things that carers, families say is essential.
Of special interest is the fact these representations do not readily lend themselves to paper media - where views coincide that point would become 'common' or congested. Should this occur throughout such an application it would throw the value of the exercise into doubt.

Recording the several perspectives, eg. patient, carer.

g)
It may be possible to adapt the HCM format to show variance in care programmes within subject quadrants. The use of integrated care plans in general health care / nursing is well documented, but what of social and interpersonal aspects of care. Are they forever off limits in this respect? Certainly in terms of "mood stabilized by third day," "no longer aggressive after six hours." What if anything might these mean? How soon after admission for assessment - query early dementia - should a (probable) diagnosis be forthcoming?

Possible application in outcome / variance assessment and summary

h) Health care policy has always been a pivotal political and social concern, but amid a world learning about the effects of global warming, globalization and spiraling health costs its importance grows annually. Health services have traditionally been 'ill-health services' and the need to move to fully oriented and integrated health promotion and education is greater than ever. Prevention is always better than cure. The health career model can also represent health promotion / education aspects.

There are requirements also to document unmet needs.

Health promotion example - beliefs, tax, resources, evidence base, culture, education, peer pressure.

Example b) above will now be expanded using four specific care problems, namely, confusion; mobility; pain, and sleep (placed in the graphic and chosen arbitrarily).

mapping problems across subject domains How confusion can be linked across HCM quadrants - concept of SELF as affected by DEMENTIA How mobility problems can be related across the HCM quadrants Link to investigate how problems associated with sleep are related across HCM quadrants To investigate pain as could be represented in the HCM quadrants

The following image is the h2cm grid presented for the GEOMED 2005 conference. In the latter part of 2005 and early 2006 the NHS now has access to Geographic datasets, an important means to combine contexts.

rule

BEWARE REFLEX MOVES - LINK TO SITE

A further example and an issue that has become a problem of specific interest to me, is that of the 'reflex moves' made by older people, perhaps when their partner has died. The problems are set out in the HCM graphic below, whilst several contexts are explored in 'Beware Reflex Moves.' These pages are intended for people contemplating moving home.

Moving - problems for older people.

Move to TopHCM Home page

top : home

© Peter Jones 1998

References:

Beck, A.T., Rush, A.J., Shaw, B.F., Emery, G. (1979) Cognitive Therapy of Depression, New York: Guildford Press.

Benner, P. (1984) From novice to expert, Addison-Wesley, London.

Berg, M., Goorman, E. (1999) Contextual nature of medical information, Int. J. Med. Informatics, 56, 1-3, 51-60.

Chiesura, A., de Groot, R. (2003) Critical natural capital: a socio-cultural perspective, Ecological Economics 44: 219-231.

Feste, C., Anderson, R.M. (1995) Empowerment: from philosophy to practice, Patient Education and Counselling, 26: 139-144.

Meppem, T., Gill, R. (1998) Planning for sustainability as a learning concept, Ecological Economics, 26: 121–137.

Wals, A.E.J., Jickling, B. (2002) "Sustainability" in higher education: from doublethink and newspeak to critical thinking and meaningful learning, Higher Education Policy, 15: 121-131.

Waterston, T. (2002) Advocacy for children, Current Paediatrics, 12, 586-591.

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