! See Also
So why am I doing this?
In addition to the more formal aims & objectives of this site, there are three reasons why in 1997 I contacted Brian and set about creating this website:
1. First and foremost I hate to see a very good idea collect dust, and not receive the recognition it deserves.
3. In 1997 the Internet was obviously the place where things were happening. At that time apart from small projects using MS Access, and a joint B.A.(Hons) in computing & philosophy I had done little practically in IT. In the early 80s - the days of the BBC microcomputer - I wrote several computer aided learning programs. (I call those the 'Sili-con Years' but they were fun, so much enthusiasm for the new technologies.)
Therefore, making Brian's notes available to a worldwide audience and explore possible avenues within HCM seemed an ideal way to contribute to Judy's site, learn some new IT skills, and publicize Brian's work.
Firstly, what of my own use of HCM?
Apart from the
1987-88 Community Psychiatric Nursing course, when fellow students
and I used the HCM for a case study, I have only used HCM to do 'think
nursing'. This particular (cognition limited) application should not
be underestimated, however, as Perry (1985); Clark
(1991); Rubenfeld & Scheffer (1995) and the work of nurse
Obviously I would like to use the model more intensively and validate some of the assumptions behind Brian's work. As students many of us queried use of HCM for the case study, being apprehensive about using a tool that had not been 'validated', although how many assessment schemes are 'valid' in the sense that they are evidence based?
Secondly, HCM is undoubtedly an 'idea'; but (as mentioned elsewhere) readers may challenge the description of HCM as a model of nursing? Although there are several definitions of 'model', Brian's work has not qualified HCM as a 'model of nursing' by meeting all the attributes that a model of nursing must fulfil, as defined decades ago by Stevens (1979) for example. This fact (a shortcoming if it is so decided?) is for me part of the HCM's appeal, as I hope to show throughout this website. Which brings us back to where we started. Why does the HCM deserve recognition?
Why is h2cm deserving of attention?
a) PRACTICE BASED IDEOLOGICAL PARENTAGE
Putting HCM's theoretical status aside for the moment - can lack of a specific theoretical influence - e.g.; behavioural; systems; interpersonal; activities of living - be positive?
It has been argued that some models are derived from such a mix of theories that the results seem like some floridly elaborated pseudo-science, rather than 'nursing theory'. A sort of professional (but that begs the question) damage limitation exercise, initiated by academics, as other professional groups more able to isolate and articulate their discipline academically, march forward to leave nurses struggling economically, politically academically, and professionally? A compensation mechanism: formulate ever more esoteric models - in a quest to earn nursing scientific status. Has 'caring' been lost (Barker et al., 1995; Biley, 1992; Burnard, 1994)? Theories can emerge that sound and look very appealing on paper and in the lecture theatre, but fail the practise phenomena they are meant to explain. Currently I have found the HCM useful in conjunction with other tools in cognitive (behavioural) and family therapy, where (collaborative) case formulation is a crucial part of the therapy process (Wills & Sanders, 1997).
In other models terms are used from other disciplines, such as, behavioural psychology (e.g., stimulus), systems theory (feedback), and sociology (groups). Terminology in models of nursing can alienate would-be users. For example, what for many readers are esoteric terms such as, heliocentricity and synchronicity as defined by Rogers (1970), do put people off theory. I have even heard nurses respond negatively to Roper, Logan & Tierney's (1980) activities of daily living model, (and h2cm!).
This is a great pity as the work of Martha Rogers and the many other theorists provides a resource and strength much needed at a time when experienced nurses observe basic nursing care being given to individuals who are (many would argue) not equipped to 'nurse'. For example, the 'nurse' in the nursing home (or hospital?) who removes an 'incontipad' soiled with dried faeces, whose sense of 'care' deems it fit only to replace soiled pad with a new one. Where is nursing practice going?
The work of theorists should not be dismissed
in the way I have witnessed so frequently. Whilst technical terms are
necessary to communicate effectively, we need to keep our feet on the
ground. Wherever nursing is needed - and that is everywhere people go
- we must remember were we came from, look to the future, yes
definitely, but also be aware of what is happening around us.
Seriously, returning back to Earth the original questions Brian sought to answer with HCM were driven by a desire to:
b) CONCEPTION - SIMPLE & COMPLEX
Any idea conceived on a train journey, and especially between Sheffield and Manchester in England, and discussed on a hot sunny day in Manchester must be special? Perhaps, the health career has a memetic property, that infected me immediately? With a presence on the web, will it now infect others, as Blackmore (1999) ponders the dissemination of ideas? What is it about the HCM that appeals to me and others - its simplicity with complexity if needed?
From the outset (while on the Community Psychiatric Nursing Cert. course) the HCM impressed me with its topological point of view. It helped me map comprehensively the realms, domains, fields, disciplines that comprise nursing, in a very aesthetic, approachable, innovative way. Its structure sought to fuse the scientific and social sciences. It is also simultaneously simple and complex.
Thinking back to my student days HCM demarcates what remain three key subject areas of nursing:
In the final version that Brian wrote, HCM incorporated an uncertainty/chaos dimension (interestingly the former is now used as the basis for a model - Mischel's Theory of Uncertainty in Illness) this then renders a 4D form when the axes of the HCM are combined with time as suggested through the notion of a 'health career'.
Health care practitioners relentlessly gather data:
Retrospectively : Currently : Prospectively
Past medical (science); psychiatric
(interpersonal and social) histories.
The interplay of time, the subject disciplines and axes of HCM create an ideal schema for assessment, care planning and evaluation. The degree of detail adopted is at the discretion of the user. Of course using HCM in itself does not ensure that assessments will be comprehensive. Poor, incomplete assessments and care evaluations can still arise. HCM can help the effective practitioner to focus on a particular area, in fine grained detail (and complexity), or coarse grained - providing an overview (simplicity).
With respect to time HCM itself remains more contemporaneous today as we enter the 21st century than it did during the 1980s?
c) INNOVATIVE An idea ahead of its time - A solution in search of a problem?
HCM is innovative in its identification and articulation of 'space'. This innovation extends beyond a mere conceptual framework to produce what may be variously called a:-
Of course all models of nursing articulate and represent their unique 'problem' space. HCM, may however, be more directly suited to spatially oriented representations, formulations and operations? The HCM could without doubt play a major role in determining aspects of nursing epistemology and informatics? Further development of HCM could now benefit from recent advances in informatics - that includes hard and software technologies. Computer based representation of nursing terminologies; problems; care plans; and assessment; require models such as the HCM. These questions are discussed in the visualization pages.
d) MULTIDISCIPLINARY TEAMS
MDT working has been espoused for many years
as the archetype for clinical practice. Surely this renders
the term 'models of nursing' rather hackneyed? Some learners
seem to get the impression that MDT is about purposely eroding the
boundaries between groups, because there is research somewhere that
suggests they are not beneficial, or get in the way of the task at
hand? Pettegrew & Logan (1989) writes:
1. the professionalisation of nursing,
2. and quest for increased scientific and political status - via curricula
remain today. Other factors also influence nurse education and practice today. Changes in health care management and delivery as in:
- impose further demands on nurse educationalists and theorists. Effective and efficient coordination, communication and collaboration of the whole team is essential to achieve:
The HCM can be adopted by any discipline. In the next century as resources are squeezed further then effective clinical risk management will continue to grow in importance - a key tenet of clinical practice. Comprehensive assessment and sharing of assessments and evaluations will be crucial. HCM can facilitate the process, acting itself as a boundary spanner facilitating interdisciplinary dialogue and negotiation. We need hybrid models of health care - NOT models of nursing, AND taking this the next logical step we need a language of health care NOT a language of nursing.
e) NURSING 'LANGUAGE'
Since the early 1980's there have been ongoing health care informatics programmes to create a 'nursing language ' or a 'language of nursing'. Why? Well very basically computers process data, and not human language, although this is fast becoming more commonplace. To manipulate data efficiently that is capture, record, store and retrieve and report results it helps for data to be coded. Without coding the volumes of data would immediately become a problem. The fuzzy world of people has to be formalized to enable representation and manipulation within the computer, and between computers as with the internet. The production of coding and classification systems have been central to this process.
So what is a 'nursing language'? Is it:
Much effort has been spent on projects to produce digital thesauri of nursing terms:
- all prompt a need for us to consider anew:
We all realize only too well how rapidly technologies change. We have amassed much experience in coding, classification and in seeking to imbue these schemes with intelligence so that it is more difficult to record nonsense, but still clinically relevant systems seem strangely evasive? To this end I wonder if consideration of the HCM and similar 'visual' tools may be used to provide a conceptual framework (or underpin) a language of healthcare. Response #3 above is what I would envisage a 'nursing language' in a computing context to be, quite an undertaking (if not impossible?). Of course the most important language of all, is the verbal and non-verbal communication that takes place between staff, patients (clients) and their carers in whatever context.
f) PATIENT/CLIENT ADVOCACY
Public (user, or patient) participation in health service delivery; planning; audit; has become a key policy goal in global health care service provision. Thus far services have only scratched the surface; indeed many services are still trying to find the surface to scratch (they are so under-resourced).
Many long held assumptions about the ability of people to hold their notes (or at least a copy), or take responsibility for personal smart cards remain to be challenged. The HCM can represent these issues, namely the political ramifications of government (economic), health and social welfare policy, personal responsibility and the wider community. Health education part of the school curriculum - part of the notion of 'citizenship'?
Health care now needs truly hybrid models, if we are to collaborate wholly - with patients, their family and carers.
g) CATALYST FOR CHANGE: CITIZENRY, HEALTH & ENVIRONMENT
If problems today require interdisciplinary solutions, then tomorrow effective transdisciplinary approaches will be crucial. This is not pie-in-the-sky theorizing. Health and social care are no longer the sole preserve of the clinic or waiting lounge. As the media has shown in diet and younger people, SARS, and AIDs; health is a national and international concern. The environment also begs with increasing urgency for our attention. We are all linked, interdependent: vulnerable. Policy makers recognise the need to engage with people politically and engender personal responsibility. Citizenship is crucial in health and the environment.
The scholastic 3Rs alone are no longer sufficient to equip youngsters for the challenges that lie ahead. Visual literacy and creative, critical and reflective skills are also needed. Is there a generic model that could be taught globally, a basis for a general studies curriculum? I obviously believe there is: but does h2cm possess the additional desirable properties in the table below? That is for you to decide…
* disarms yet empowers
© Peter Jones 1998
Thank you for your interest - please visit again soon.
Barker, P.J., Reynolds, W., Ward, T. (1995) The Proper Focus Of Nursing: a critique of the caring ideology, Int. Journal Nurs. Stud.,32,4.
Biley, F. (1992) Nursing models redundant in practice, Nursing Times, 15, 219.
Blackmore, S. (1999) The Meme Machine, Oxford Univ. Press., 216.
Boisot, M.H. (1995) Information Space, Routledge, London.
Burnard, P. (1994) More humble, less mumble, Nursing Standard, 8, 32, 50-51.
Clark, J. (1991) Nursing: an intellectual activity, BMJ, 303, 376-7.
Jones, P. (1996) Do we need an Overarching Theory of Health Communication? Health Informatics, 2,14-16.
Lefebvre, H. (1991) The Production of Space, Blackwell, Oxford.
London, P. (1988) Metamorphosis in Psychotherapy: slouching towards integration, Jour. Integrative and Eclectic Psychotherapy, 7,3-12.
Norcross, J.C., Arkowitz, H. (1992) The evolution and current status of psychotherapy integration, Integrative and Eclectic Therapy, Dryden W., (Ed.) OUP, 1-40.
Perry, J. (1985) Has the discipline of nursing developed to the stage where nurses do 'think nursing'? J. of Adv. Nurs., 10, 31-37.
Pettegrew, L.S., Logan, R. (1987) Health Care Contexts, Handbook of Communication Science, Berger CR Chaffee SH (Eds) Sage Publications Ltd, Chap 22, 675.
Rogers, M. (1970) An Introduction to the Theoretical Basis of Nursing, Philadelphia, F A Davies.
Roper, N., Logan W.W., Tierney A.J. (1980) The Elements of Nursing, Edinburgh, Churchill Livingstone.
Rubenfeld, M.G., Scheffer, B.K. (1995) Critical Thinking in Nursing: An Interactive Approach, Lippincott Co., Penn.
Stevens, B. (1979) Nursing Theory, Analysis, Application and Evaluation, Little Brown.
Wills, F., Sanders, D. (1997) Cognitive Therapy For Counselling, Sage Pubs. Ltd, London, p.30.
Thank you for your interest which is greatly appreciated.
Whether a patient, partisan, pauper,
patrician or professional, everybody needs:
help-2c-more - help-2-listen - help-2-care
© 1998-2003 Health Career Model by Brian E Hodges.