Keywords: Change, Equilibrium, Systems, Entropy, Dynamism, Process, Outcomes

Citing this page:

Jones, P. (2000) Hodges' Health Career Care Domains Model, Change:

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Change is a characteristic of all things, especially living things. Rather perversely in physical terms a stage of 'equilibrium' is only reached when we die. Spiritually and materially of course the substances that make us and other living things continue to change after we are long gone. Between conception and the end of life, people change in response to genes, environment, life experience, education, disease and trauma. From birth to death the qualititative and quantative impact of concepts such as: balance, equilibrium, stability, stasis, and neutrality, apply to each and everyone of us. If we are fortunate able to avail ourselves of the chances that life affords much is taken for granted.

Brillouin (1949) ponders philosophically:

'Consider an adult specimen, be it a plant or an animal or man. This adult individual is a most extraordinary example of a chemical system in unstable equilibrium. The system is unstable, undoubtedly, since it represents a very elaborate organisation, a most improbable structure (hence a system with low entropy, according to the statistical interpretation of entropy). This instability is further shown when death occurs. Then, suddenly, the whole structure is left to itself, deprived of the mysterious power that held it together; within a very short time the organism falls to pieces, rots, and goes (we have the wording of the scriptures) back to the dust whence it came.'

[Brillouin L (1949) Life, thermodynamics, and cybernetics. In Maxwell's Demon Entropy Information Computing , (Leff H.S. & Rex A.F. eds), Adam Hilger, Bristol (1990)]

Introduction

The concept of change has been manifest from time immemorial. The ancient Greeks were very conscious of change. Basic survival dictates that all species are constantly aware of and able to respond to change. Intelligence and language are requisite tools for adaptation, giving us an edge over flora and fauna that must 'change' within just a few generations not over several millennia. Today - in the west especially - change is information driven. We can now move information with an efficiency that continues to grow at a relentless pace, this engenders further change, making prediction difficult. Change brings both marvellous opportunities and perilous risks depending on your viewpoint.

Today our pre-occupation with change is marked due to:

• the speed of change;
• the scale of change - globalization;
• the scope of change - influence on the individual and family unit;
• associated uncertainties;
• the permanence of change;

This page seeks to introduce change, relate the concept to the health career model and its care domains, concluding with reference to objective and subjective health and change at a demographic level.

Change drivers: biology, technology and time

Technology, such as that you are presently using, provides us with an ever increasing ability to collect raw facts as data. As technology penetrates our culture, our senses are enhanced. Space probes, electron tunnelling microscopes extend our sensory range. The changes we can detect therefore range in granularity from the 'beginning of everything (or when)' to rendering matter inert at absolute zero. We are now aware of change at levels previously beyond our perceptual faculties. Various parts of the body can be replaced. Medawar (1984) refers to these instances as 'exosomatic'. We have, for example, 'exosomatic kidneys' in the form of kidney dialysis machines. The processing and storage capabilities of computers are becoming 'exosomatic brains'.

A further way to consider change is born of our knowledge of our own 'metadata' - data about data - and that of other species. Manipulating the human genome might fuel change with perilous possibilities. A potential that frightens many people with the power to change the essence of humanity - should someone decide to use it. Nanotechnology has become the latest example with debates on the possibility of unleashed technologies bringing about not only the end of the humankind - but the whole world. How far should boundaries be pushed? From stem cell research to the cloning of humans the debate and concern continues. If you are leaning backwards bedazzled by or resisting change, or you have your head down in a headlong rush to keep up with change, how do you recognize a slippery slope?

Measures: Data, change, health and social care

Whatever the mysterious force that holds us and everything else together and our beliefs as to the nature of that force, every living thing possesses a health status. Even before this in purely binary terms we have life status, we are either dead or alive, hence the ethical, legal, and social problems when people seemingly fall in-between these states.
The word status is important. Status also denotes change. How can this be, when someone holds a position of some status in the community? Well, perhaps it is the possibility of change (planned or unplanned) that is ever present, which accords the position its value and prestige.

We live now in the age of life-long learning. Governments are keen that the working population should constantly update. Educational stasis is bad for the individual, and the national economy. Practitioners in education and health care use reflection as a key tool to evaluating their work and methods. What do we reflect on? Changes - both expected and unexpected:

• session (whether educational or clinical) outcomes;
• emotions why do I feel the way I do - how does the student / client feel?
• how could I have changed outcomes?
• what did I learn from that encounter?
• how did that session compare with the last?
• how does that experience fit in with:
  - care objectives
  - learning objectives?

In their transition from beginner to expert, students quickly realize that the changes that they must concern themselves with cover diverse phenomena and events. Within the hands-on health care arena change is all around us of course, both change for the positive and change for the negative, the latter which we seek to ameliorate or reduce the effects of, the former to maintain and enhance. Looking once more at the characteristics of data, change in specific attributes is crucial in differentiating significance and so assigning priorities.

Of course situations dictate the specific change that demands our attention, inclusion in an assessment, evaluation:

• noting changes in the healing of a burn wound using a photograph and notes.
• weight of a client with eating disorder
• attitude and cognitions of a client to their situation in final weeks of cognitive therapy
• family responses to bereavement/loss
• lithium level blood results
• gait analysis in physiotherapy
• presence of suicidal ideation

Hodges' Health Career - Care Domains - Model & Change

In order to determine change we must decide on how to measure it, be that by observation, ruler, Likert scale, Beck's Depression Inventory, or micrometer. Even before this however, we must in many circumstances set constraints on the process of measuring: how often, what area, what frequency of observation. Although everything changes not all phenomena are subject to measurement. Placing boundaries is an important facet of what people do. A community nurse might focus upon one area - social - for example, on one visit while the physical domain arises on the next contact, due to problems with medication perhaps.

To say that 'we' take an holistic perspective in our health work may becoming as difficult as it is for GP's to maintain adequate knowledge of the medical domain - and they are certainly under pressure in this respect. Informatics is proposed as a solution to the dissemination of knowledge. Perhaps the HCM also has a role, in framing holism in health care?

HCM can prove useful because the interdependency between domains can be displayed. And crucially whereas previously 'taking in the whole' has been the prerogative of the nurse, on behalf of the patient, today both patient and nurse should collaborate and share the holistic aspects of the situation - both positive and negative.

As per the page on contexts and potential application of HCM the HCM quadrants will again be used to highlight holism and change within nursing, health care and social welfare. Next the HCM is used to highlight clinical / health related situations where an awareness of 'holistic bandwidth' may prove useful? Whether this will work is for you to decide. Each quadrant will be taken in turn:

INTERPERSONAL

The holistic bandwidth towards and at the humanistic extreme are by far the most complex. Here we can only 'scratch the surface'. For example, in cognitive behaviour therapy a principle part of therapy is socializing the client in the cognitive model. Helping them to discover, for temselves, the 'whole' picture. How situations, thoughts, feelings and outcomes are connected for them. This is achieved through guided discovery.

The health record captures that state at a certain point in time, knowledge that can prove very useful as a benchmark to monitor change, response, attitudes.

The HCM can help to record transition, across the subject disciplines and multidisciplines that make up the knowledge base and health care team.

Physical change often proves the most manifest form of change, especially as a result of accident or natural disaster. Change occurs however at the micro and macro level. Changes in cells preoccupy the histopathologist, physician, patient and their families. Systemic infections focus attention on temperature and other homeostatic indicators. Sudden change in physical environment can alienate and disorientate confused people. Non-concordance with drug regimens may lead to a relapse of depression, or lack of therapeutic response when medication is given up after 4-5 days there being no apparent improvement. Returning to the macro (global) level our weather is said to be changing, calling for changes in people's behaviour.

There are characteristics we hold that are usually not subject to change. If change is sought, such as in gender then a lengthy process of consultation (interpersonal-psychological) takes place and whilst change may occur physically, socio-legal (political) change is also no trivial undertaking. The reaction of family (social) can of course vary across the whole response spectrum. Proteomics and ultimately gene therapies will challenge the previous millenias interpretations of 'normal', 'change' and 'benefit'.

Political change also covers a broad range of health and social phenomena, and vital factors such as education. Advocacy first, however, rather than contacting the patient's physician to prescribe sedation for an unsettled rest home resident, the community nurse may try to find out why a change in behaviour has occurred. If still unresolved perhaps a change of environment is needed, although staff may not wholly agree. Although the patient may not be able to request a move to more appropriate accommodation others must do so if needed, rather than a resort to a so-called 'chemical fix'.

Governments seek the ability to account fully for health care expenditure, hence the long-term desire to create a unified, comprehensive [electronic] health record, one that within the EU transcends national borders. A struggle as technology, associated costs and Governments [policies] all change. Integrated care pathways anticipate change, charting the planned progression through a care episode which can then be audited.

Epidemiological changes in the population must be dealt with politically. How are pensions to be managed in future? How far must climatic change continue before politicians forget about their next term and consider the term awaiting future generations? How will global warming affect the world's mental health? What are the implications for water supply in already drought ridden countries of the world? Alternately how will precipitation changes affect the incidence of flooding? How much does climate affect health?

Whilst the existence and inevitability of tax and death do not change: people do. Definitions of 'family' have changed in the west, and are under pressure in other spheres. Social change occurs in obvious and subtle ways, at the level of population and family units.

Recognition of change is a key determinant in family and interpersonal therapies and interventions.

The need for balance: Objective and Subjective Health and Social Care

The examples above stress the multicontextual nature of health. Few problems are exclusively the province of a single quadrant. Most straddle two and depending upon the boundaries set (consciously or not), other problems may extend across all four quadrants.

The main rationale for inclusion of this page on 'change' is made above. If justification for the HCM is to be linked to this concept, what evidence is there? Sullivan (2003) articulates a role for the HCM implicitly. Describing the rise of 'subjective' health and the significance of:

1. Perspective
2. Qualitative measures
3. Quality of Life
4. Body vs Life

As explained elsewhere in this website, medicine's historical roots in science epitomised in the autopsy, objectifies the individual. The mechanistic is preeminent. We are learning through policy and integration and interdependence of health and social care that the patient's perspective is essential when the emphasis is placed on 'life' not just 'body'. Qualitative measures have a critical role to play, but in the West as health and social services are stressed in the demographic changes to follow how well placed are we to cope with the information flows prompted by this increase in holistic bandwidth? Consider the figure below:

CHANGE: Demographics, Ageism, Depression

One of the most important factors driving change, service reconfiguration and attention to global trends, is the rising proportion of older people in the population. The World Health Organization (1998) reports that there are approximately 590 million people over the age of 60, but in just 25 years that number will double to 1.2 billion. In the UK the number of older people over pensionable age (taking account of the change in women's retirement age) is projected to increase from 10.7 million in 1998 to 11.9 million in 2011, and will rise to 12.2 million by 2021. Women currently begin to outnumber men from around the age of 50, and by the age of 89 there are about three women to every man. Between 1992 and 2021 the number of people aged over 65 is expected to increase by nearly a third, by which time there will be around 12 million people, aged 65 or more - 19% of the population (National Statistics, UK, 2000).

Such statistics result in titles depicting crisis: Fit, willing and able? Is Britain ready for 2020 (BUPA-MORI, 2002)? Commentators focus upon the dependency ratio, an indication of the balance between those employed and those dependent upon them. Soldo & Manton (1985) noted the trend towards pessimistic headlines, portraying reduced mortality not as a triumph, but more an impending disaster for society. More pointedly, they write of 'population metabolism', how elderly population cohorts interact with other societal groups provoking change elsewhere. No part of society will be immune. Cohort turnover will increase, i.e. the rapid, mortality-induced succession of birth cohorts with very different life histories and preferences, dictate dynamic planning by all societal components. Contrast the intergenerational differences between current 60-70 year olds through to 85 and over.

Significantly, demographic issues draw attention to the complex interplay of forces that necessitate awareness of the quantitative and qualitative dimensions of population ageing that will shape our collective future. This interplay will effect changes in life expectancy and related trends in morbidity and disability. Inevitable consequences of an ageing population are obvious; numbers do speak volumes. Although acknowledgement of Soldo and Manton's warning requires exploration of more subtle, qualitative effects and consequences. Women survive longer than their male cohort peers, and have a higher life-time risk for depression - 12% for men and 20% for women (Sturt, et al. 1984). The growing significance of this population contrasts starkly with the knowledge base pertaining to it; a great deal that is unknown about this section of society.

In order to make objective sense for organizational purposes of the subjective social world, health services are forced to categorise and hence pigeonhole people, resource allocation follows for health and social services. Therefore, services seek to differentiate between the mentally ill, older people, and the disabled, but some people are simultaneously disabled, mentally ill and older.

Amid concentration at one end of the life career, there is also the potential of ageism directed at younger people. The 'spoilt', 'selfish', 'irresponsible' generation that haven't earned a thing. These sterotypes allied with the burogamy - the state taking over as pivotal financial provider for the family - will create severe tension in the call on resources. Education and good health are essential if each cohort of younger people are to be productive, efficient, adaptable and resilient (Burt, 2002). Crucial not just for them and their life and health careers, but for everyone.

To close this section the discussion raised here is illustrated using the HCM (to follow).

© Peter Jones 2000-2003.

References:

BUPA-MORI (2002) for the BUPA Health Debate 'Working Britain: 2020 Vision'.

Burt, M.R. (2002) Reasons to Invest in Adolescents, J. of Adol. Health, 31: 136–152.

Medawar, P. (1984) The Limits of Science, Oxford, OUP.

Soldo, B.J., Manton, K.G. (1985) Demographic challenges for socioeconomic planning. Socio-Economic Planning Sciences, 19(4) 227-247.

Sturt, E., Kumakura, N., Der, G. (1984) How Depressing Life is - Life-Long Morbidity Risk for Depressive Disorder in the General Population, Journal of Affective Disorders. 7: 109-122.

Sullivan, M. (2003) The New Subjective Medicine: taking the patient's point of view on health care and health, Soc. Sci. & Med., 56, 1595-1604.

WHO (1998) Fact Sheet N°135, Population ageing a public health challenge. Sept.

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