Keywords: Health Career, Contexts, Conceptual Framework, Care Domains
Citing this page:
Jones, P. (2000) Hodges' Health Career - Care Domains - Model, Multicontextual Nature of Health:
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:
In health care our frameworks must also be multifunctional (very!):
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?
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.)
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.
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.
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.
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
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:
The examples a - h outlined graphically below are merely suggestive, the variations are legion?
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.
© Peter Jones 1998
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.