Keywords: Information Levels, Holistic bandwidth, Systemism, Stress, Elaborations, Globalisation, Ecology, Drake's equation, Environment

Citing this page:

Jones, P. (1998) Hodges' Health Career - Care Domains - Model, Information Levels

<>, Accessed

INTRODUCTION

Surely no handle, however forged can grasp and encompass the vast range of health & social care phenomena? The task is impossible so why bother? As an example from the past in seeking explanations to conjoin the varied states of ice, water and steam, John Searle affirms in Magee (1987) that:

'the sheer diversity of the phenomena should not by itself discourage us.'

Well, let us try. The purpose here is not to seek an information processing model as defined in psychology or computer science, but to explore the range of health phenomena, our engagement with these phenomena in clinical practice, and in formulations, such as, the HCM matrix. Justification for the structure will also be introduced. The range of phenomena is suggested here:

1. The importance of social factors, carers, families in health. Value must be accorded to qualitative perspectives and research approaches. Petticrew (2001) There should be a place for what Mays & Pope (2000) refer to as subtle realism, research that is ' more about representing reality than the truth'.
2. Engaging populations in health education/promotion. How has the shift from citizen to consumer affected health care? How can individual responsibility be mediated in policy? Urry (1999)
3. Changes in climate and the biosphere - effects on populations and individuals, how can the environment be factored into health Chukwuma (1998)?
4. Balancing the indicators - quantity (work completed) and quality (outcomes gained).
5. Balancing scale and subject, that is locale-global and individual-population.

The debate in social science (and health studies) regarding individualism, holism and systemism is limiting according to Bunge (2000). Health's appeal to holism is insufficient theoretically and practically to deal with the 21st Century. Perhaps, information can provide a basis to weld the disparate schools of thought together, to provide solder between concepts. Simultaneously, perhaps informaticians can assist in provide effective information solutions that respond to the work environment with benefits that are not accidental - a positive serendipitious event.

In this quest academics and practitioners are stymied due to the sheer physical world we inhabit. Philosophers state that human beings cannot stand back from, or get outside our language in order to find the pure essence of concepts, of human reality. Magee (1987). Use of language whether written, verbal, or an 'abstract' language such as mathematics entails information formulation, processing, and transmission. We cannot avoid this. In certain contexts even choosing not to communicate is a statement. Watzlawick et al. (1980) Information is the keystone between human experience and the external world. In Stonier's (1990) Information and the Internal Structure of the Universe the author notes:

'... if the first axiom of a general theory of information is:

Information is a basic property of the universe,

the second axiom must be:

The information contained by a system is a function of the linkages binding simpler, into more complex units.'

This second axiom matches the structural model of biology. In cognitive psychology successive refinements and new findings (e.g. mirror neurones) provide new insights into consciousness and behaviour. Models with neuronal assemblies of increasing complexity are proposed and described by Minsky (1969), Dennett (1991) and Edelman & Tononi (2000), research in cognition is informed by the new sciences of chaos and complexity, that open new avenues.

Information, whether - new, old, social, scientific, reductionist - seems to hold promise. Stonier (1990) also provides a handle, a foundation upon which to build. A derivative conclusion of the second axiom is given as:

'The universe is organised into a hierarchy of information levels.'

INFORMATION LEVELS for HEALTH & SOCIAL CARE (and beyond?)

Table 1 is a proposed hierarchy, which is similar to countless others in the literature. I seek to justify the extent of Table 1 in the discussion following.

TABLE 1 DOMAIN/INFORMATION LEVELS

DOMAIN/ INFORMATION LEVEL	THEORETICAL AND EXPERIENTIAL DENOTATION
[SUB-ATOMIC]	QUANTUM MECHANICS. FREE WILL. DETERMINISM.
[ATOMIC]	FUNDAMENTAL FORCES OF NATURE. NUCLEAR. WEAK. STRONG. ELECTROMAGNETIC. IMAGING TECHNOLOGIES, X-RAYS, T-RAYS, NANOTECHNOLOGY
MOLECULAR	MOLECULAR BIOLOGY. NANOBIOLOGY. PHARMACOLOGY.
CELLULAR	DNA-RNA REPLICATION. HEREDITARY. PROTEIN METABOLICS
SYSTEMS: Eg., COGNITIVE	PERCEPTION. SELF. REALITY ORIENTATION. KNOWLEDGE APPLICATION AND REPRESENTATION. CATEGORISATION. ACTION. MOTIVATION. VOLITION.
SOCIAL	COMMUNICATION. GROUP BEHAVIOUR. FAMILY. VALUES. MORALS. PERSON.
ORGANISATIONAL	COMMERCE. COMMON PURPOSES. POLITICAL. AGENCY.
CULTURAL	CONSUMERISM. PARADIGMS. ATTITUDINAL. SPIRITUAL. EDUCATION. BELIEF SYSTEMS.
POLITICAL	POLITY - GOVERNMENTAL SYSTEMS, LAW & ORDER. ECONOMIC CONTROL. DEMOCRACY. CITIZENSHIP. GLOBALISATION. REGIONAL, NATIONAL, INTERNATIONAL CONTROL. INTERNATIONAL STANDARDS. POLICY,. ECOLOGICAL POLICY INTEGRATION
GLOBAL - BIOSPHERE	POPULATION. ECOLOGY. ECOLOGICAL ECONOMICS, ENVIRONMENT.
[ASTRONOMICAL]	COSMOLOGICAL CONSTANTS. EXISTENCE OF LIFE. PLANETARY SYSTEMS.

Table 1 radically extends the hierarchy displayed previously. The bracketed information levels (sub-atomic, etc.), dealing with quarks, particle accelerators are included in the structure, but they are not as Downs (1995) states the 'subject matter of nursing'. Why include them? How can the information and computer sciences inform health and social care? I considered this question in Jones (1996), noting, like many other authors the ubiquity of information. It is implicit within all models, in all disciplines, that 'information' provides a metamodel. This is why these levels are included. There is no choice. 'Information' provides the starting point, for all deliberations, but table 1 raises several questions:

1. Why be so extensive? Where is nursing in all this?
2. What other schemes exist and how are they differentiated?
3. Where does holism figure in the proposed formulation above?
4. Why is an infocentric schema (or any other) relevant in addressing the issues health & social care faces in the 21st Century?

The remainder of this page debates these questions.

WHY BE SO EXTENSIVE?

Whichever conceptual frameworks are identified, it goes without saying that they will need to be extensive given the eclectic nature of health and social care. From where in this hierarchy does nursing (health care), survey the world - top, bottom or middle? A moments reflection and the student nurse and social worker and other learners can immediately see the relevance of the levels from:

MOLECULAR to GLOBAL -

but from SUB-ATOMIC through to ASTRONOMICAL - surely not (as the apologetic brackets might suggest)!

Justification is in order. Within this site the status of nursing as a science is used to argue the case for visualization in health and social care. If we take the robustness of the hierarchy in table 1 for granted, then science can undoubtedly act as an initial anchor hold, calling upon biology, chemistry and physics (of the 'brute' force kind). Quantum mechanics, however, and the course of stars and planets across the heavens? Perhaps there is a 'typo' and he means astrology? This is after all the 'new age'? Inclusion of astronomy is no mistake. A little digression seems in order.

Since nursing strives for scientific standing, then nursing theory must recognize its dues to astronomy.

Astronomy: the first science?

The spur for the first questions. Why are we here? How did life evolve? Are the stars campfires of other peoples? What are we? Are we ...

'... starstuff pondering the stars; organised assemblages of ten billion billion billion atoms considering the evolution of atoms; tracing the long journey by which, here at least, consciousness arose.' Sagan (1980).

I have long marvelled at the implications of Drake's equation, shown below, which calculates the possible number of civilizations (N) in the galaxy capable of advanced communication:

OFF AT A TANGENT SURELY?

Ultimately the environment, population growth and pollution affects people's health. Critically, there are many questions to be asked, answered and solutions integrated, specifically how stewardship, sustainability are reconciled against ageing populations in the West and lack of education - poverty in the developing world (Wright & Lund, 2000).

This in turn impacts upon the health care burden faced not only by nurses and other health professionals, but every living thing on this planet. ICT is helping to identify the problems. Satellites provide stunning panoramas and data on global warming in action at the poles. The annual waxing and waning of the ozone layer over these regions is monitored. Remote sensing give us insight into biospheric factors that affect our health: skin cancer, cataracts, damage to crops, water resource, ecological imbalance in regions of the world, and the movement of disease vectors as described by Kleiner (1995).

Globalisation is a term of increasing significance economically; prompting research into the Just Third Way, binary economics and attempts to produce a post-Marxist critical social theory that places ecological concerns at its core (Finbar White, 2003). Global perspectives have greater relevance each year. When applied to health care, the global picture becomes ever more crucial given the debate about population control, pollution and concern for our environment, its flora and fauna. How well does Western science reconcile soil health to the health of the communities (and economies) that depend on successful cultivation (Sturz & Christie, 2003)?

What will be the effects of climate change on health - physically, mentally, socially and politically especially in parts of the world with high vulnerability such as Bangladesh (Nelson, 2003. In 2003 the precarious state of efforts to intervene and manage global warming has come to the fore, with evidence of deaths attributable to climate change (WHO, 2003); and the ongoing need for study with the contribution of soot to this phenomena (Shine and de F. Forster, 1999).

Researchers now debate the need for outcome measures using the construct of quality of life that combine environmental quality of life - EQOL and health related quality of life (HRQOL) (Lercher, 2002). van Kamp et al. (2003) extend the environment/quality of life question, by explicitly demarcating the relevant concepts to enable an important project:

The proposal concerns an Integrated Project on Urban development, Environmental Quality and Human Well-being and has the following objectives:
(1) To gain knowledge on environmental quality (physical, social, spatial) and subsequent effects on health and well-being across European large cities.
(2) To develop an integrated transdisciplinary and intersectorial approach and a digital toolkit to properly assess, monitor and potentially forecast developments of environmental quality and well-being.
(3) To make a toolkit available, tested on its applicability to real life policy and decision-making activities/planning.

Climate change focuses attention on the fact that there are several ways of defining health - ecosystem health being one of the most important, such is its potential impact on all the others (Guidotti, 2003).

Currently, it is only possible to estimate (thankfully?), the probable lifetime of technical civilisations. Martin Rees (2003) poses the question of humanity surviving the 21st Century. It is known, however, that environmental stress results in stress for the masses. Stress in technical societies is a fact of life. One symptom and sign of technology's inexorable rise. In the 'information age' Dunlop and Kling's (1991) 'Seductive Equation' is assumed to be true, that:

Technological Progress = Social Progress

When viewed globally this equation can be interpreted as:

technological progress in the affluent nations means static or decreasing social progress in the rest of the world. Bessant (1987)

Perhaps stress can be described more formally?

Stress = (Applied Technologies, Rate of change (innovation), Coping abilities (including technological benefits), Planetary resources-Ecological footprint, Value assessment (technology assessment)).

Humanity must learn to handle these (and many other) variables intelligently. The time for 'guesstimates' is past. We need knowledge about the dependency of these variables upon one another, what is there sensitivity? This is why table 1 - the information hierarchy is so extensive. Many concepts (such as 'information'!) remain highly abstract, our understanding incomplete, as befits our immature use of technology. Having helped with identification of the problems, ICT and collaborative tools may confer the ability to handle them with the deftness and care required.

'Environment and health have become nearly interchangeable concepts in post-traditional societies. We are able to observe almost an obsession with them, as if individual changes in ways of life - important for the individual and significant for the culture though they may be - possessed the power to overthrow a system of economic relations that aims at growth in numerical terms rather than in development, enabling society to sustain its specific modes of private and public interaction. From the point of social change, it does not make much difference whether one engages in one or the other arena. Both are weak players in political terms, and both are currently so diverse in concepts that they do not present a substantial threat to the established political and economic system.' Wenzel (1997) p.414.

A fundamental challenge for health (nursing and social care in all its forms) is that of boundaries. How the scope of a discipline and its curriculum is defined and allowed to 'twinkle'. Twinkle seems an apt descriptor, since over time parts of the curriculum will shrink or be withdrawn altogether, while others grow. The question of what is of relevance to nursing (health) is now acute. A debate taken up very vigourously and persuasively by Kirk (2002). Although the medical model often omits the foundations of individuality, it is nonetheless egocentric. This is not only a problem in terms of not acknowledging the individual as a being with a need for meaning, possessed of roles and beliefs. Kirk argues that this stance is insufficient - we must seriously consider a shift to an ecocentric focus.

Although in many western nations population growth is static (or even declining), population issues grow in significance each year. McMichael (1993) highlights how the WHO's definition of health is a:

"fine ideal for the individual, but it is not an appropriate way to think about the health of populations. Populations never are free of disease, disability and premature death."

We need health goals that are framed "in relation to population health." Ibid.

This is an excellent aspiration and one that demands from one global organisation a fundamental shift in policy and some argue the very existence of others. The global justice movement gives the middle classes (everywhere) cause for reflection - do they stay in their politesse mode, or seek to change their own political systems?

That the colonised world, whose wealth has been plundered for 500 years, should be deemed to owe the rich world money, and that this presumed debt should be so onerous that every year $382 billion, which might have been used to feed the hungry, to house the poor, to provide health care, education, clean water, transport and pensions for people who have no access to none of thse ameneties, is transferred from the poor world to the anks and financial institutions of the rich world in the form of det repayments is an obscenity which degrades all those of us who enefit from it. It is an obscenity perpetuated by the very system which was, or so we are told, designed to bring it to an end. Monbiot, (2003), p.158

Inclusion of the individual and groups of people in all forms are crucial in any formulation. This distinction is fundamental within Hodges' Health Career Model. Within a hierarchy, however, we need a mechanism to differentiate the levels. Even if this differentiation is done 'on-the-fly' in practice, theory demands rules be identified?

What other schemes exist and how are they differentiated?

The table below repeats the initial biological hierarchy, the proposed information levels above, and two further examples. The literature provides a plethora of examples, simple, complex, depending on purpose and context.

Basden (1991) above defines a set of irreducible levels, a scheme designed to help make computers easier to use. A rationale not exactly sympathetic to our purpose here. A key criterion in Basden's levels may be of use however, which is:

	'that a level is a true level if it cannot be derived from those below it.'
A rhetorical question at this point, but what is the outcome of applying this rule to the hierarchy (or any other framework) discussed here?

Where does holism figure in the proposed formulation above?

The cursory literature review completed here, repeatedly comes across the fact that health has more than any other discipline become trapped between a series of polarities. An observation noted by Lindeman & Sirelius, (2001):

Tomkins's Polarity theory suggests that ideologies in a vast array of domains are polarized on these same issues (Tomkins, 1963). In addition to the polarity between the political right and left wing, examples can be found in mathematics (the conception that numbers are real vs. the conception that someone invented them), metaphysics (a realistic vs. an idealistic conception of the relation of a human being to reality), ethics (perfectionism vs. happiness), jurisprudence (law as transcendental vs. manmade), art (traditional vs. experimental) and education (authoritarian vs. child-centred). (Tomkins, 1963; St Aubin, 1996).

This brings us to an information level that is glaring in its omission, although it is present, but not listed explicitly. Ethics must be factored in. For many

Bunge (2000) argues that a systems view can span the usually opposed schools of individualism and holism. Diagrammatic tools may explicate how this disparate triad approaches can (and desperately need to) be conjoined. The need for differentiation then becomes less problematic, but the requirement does not disappear completely.

Bunge (2000) proposes the Boudon-Coleman diagram to condense micro-macro analyses.

Just as in research there is recognition that the quantative and qualitive need to complement each other, and at times join forces to answer certain questions. So too health needs ways of integrating the micro and macro levels of theory and practice.

It is hard to see around corners, still even harder a task to envision a connection with a discipline that is not in the same neighbourhood. To overcome this you must either: clear ones mind and travel or rely on the benefit of long range communication media to capture the knowledge of others. One researchers' insight can be another's eureka moment: a patients' hope. This is no doubt the role of imagination in science, the role of creativity. The often quoted mantra - the need to think out of the box - and peer over somebodies shoulder. This assumes of course that knowledge is organised in structures we can recognise. This is one advantage of E-media pulling together knowledge and structuring it on-the-fly. Within the structures created we must beware the assumption that they are purely dynamic or purely static, but probably changing over time and according to context.

A further difficulty is due in part to Tomkins's Polarity theory when mixed with closed reductionism with its obsession with boxes, categories, or compartments. Burkart (2000) criticises the pursuit within molecular biology and cell physiology to define dose-effect relationships and thresholds for single toxic agents in our environment. Debating single-agent toxicity in splendid isolation is deeply flawed in view of a modern, but stresses the need to extend and change the approach:

However, in environmental science, these insights are obtained at a price: firstly, it is difficult to recognize, let alone to take into account what is lost during fragmentation and dissection; and secondly, artificial compartments such as scientific disciplines become self-sustaining, leading to new and unnecessary boundaries, subtly framing scientific culture and impeding progress in holistic understanding. Burkart (2000) abs.

If the ladder above represents both the tendency to polarise and compartmentalise phenomena, then the clarity of adopted terminology such as scaffolding and blending of knowledge becomes clear (Steichen, 2002; Walsh, et al. 2002; Neitzel & Dopkins Stright, 2003; Liu, 2003: (in press)). While scaffolding has been largely applied to the task of facilitating learning for the individual student, there is the need for assistance in integration across disciplinary boundaries ('boxes'). Health and social care can certainly lay claim to consilience being an essential goal in the achievement of a full understanding of the human and global condition. The two cannot: must not; be separated. The affinity in the task of striving for consilience and potential of Hodges' conceptual framework (and others: literature search?) unites the micro-macro, the reductionist, holist and systemism paradigms the forging of blended research that retains the value of reality.

How can this schema (or any other) assist us in addressing the issues health care faces in the 21st Century?

When conducting a routine home visit, then it is true, the vast majority of information levels listed above are not relevant. There are, however, theoretical and social issues that transcend the day-to-day world of health care delivery. The issues facing each one of us in the 21st Century will demand much and forgive little. Politics is not this site's raison d'etre, and yet people's opting out of the political process is very worrying at a time when participation is needed. People need to be encouraged to think critically, to balance arguments coherently, instead of opting out. There are signs that the 'popular' vote can be mobilized, and with increasingly effective results aided by communications technologies.

Perhaps, this is a sign of positive change, and yet as the saying goes - 'the more things change the more they stay the same'. What happened to the goal of an increase in the proportion of the world's population with an education? What does the return (not that it had left the world's stage) of T.B. and other diseases, say about existing systems? The things [health, education] that require most funds, so often get less than they need. Clinicians must have the tools to make "health for all" and other global initiatives a reality. That includes tools that can also engage patients, carers, policy makers and managers.

It is not only in health that new educational tools are required. Health and information policies propose that people should carry (either possess directly, or have access to?) their own health records. New ways of representing, presenting, manipulating and processing that information become an urgent necessity. Possession of such records accords autonomy in the holder, and with autonomy resides responsibility. Responsibility in turn requires critical thinking; a central element in health and environmental education (and beyond?) as Mogensen (1997) describes in four perspectives:

1. The Epistemological
2. The Transformative
3. The Dialectical
4. The Holistic

'The fourth perspective of critical thinking, insists that critical thinking involves both feelings and reason. It does not accept that thinking is to be understood as a purely cognitive and intellectual matter without emotions, feelings and intuitions. Critical thinking is human rather than mechanical.' Mogensen p.434.

'Environment and health are not isolated arenas of political dispute. They are part of a comprehensive system of local, regional, national and international interdependencies of political and economic power structures. We are not alone anymore, if we have ever been. Whatever happens somewhere on this planet, it will have an impact on our individual and communal living conditions and on the ways how we see the world. We are on our way although nobody knows where the journey will lead us. However, one thing is clear:
'The almost insoluble task is to let neither the power of others, nor our own powerlessness, stupefy us.' (Adnorno 1974, p.57.) Wenzel (1997) p.415.

It is ironic that for technology to work for people, defining our problems as solely "technical" is insufficient. Technical problems are a specialised form of social problem. Mumford (1991) The humanistic fuzziness in nursing and health care is a strength, not something to be completely shackled to scientific terminology and technology laden apparatus.

In this section I have done the opposite of throwing out the baby with the bath water. In a cut and paste frenzy of various (academic) 'bits and pieces', the bath "over floweth" so to speak. The risk of getting lost amid this particular concept of information is ever present.

Hopefully, however, it is not just a case of providing a sense of direction - "go that way", but a sense of 'necessary direction' "we need to go that way, and this is why." Necessary direction with a sense of urgency. From clinical governance to global governance (Monbiot, 2003). What point is there for health and social care workers in attending to the health needs of individuals, when the environment they live in is severely degraded. Many authors recognise the need to make caring and healing the prime factors in theory building and practice, also recognising the need to extend caring and healing beyond the individual, and what is normally considered 'the' group - family. Bent (1999) supports the arguments here stating:

'It has been proposed that caring is the interactive exemplar of nursing; that it is what relates other foundational concepts of person, health, and environment within the human science paradigm. 1 There is a substantial body of nursing knowledge developing around the ethics, the ontology, the knowledge, and the praxis of caring for individuals. However, the practice of nursing is broad and additionally includes communities, the environment, and the global society, and as such, needs to reflect caring in these arenas as well.' p.29

Are the levels irreducible? Where are the boundaries, or the overlap of fields, the point of transition from the atomic to molecular to cognitive to the social? There is a need to develop (or redefine?) the framework and attempt to integrate the various contexts that arise in nursing. Are there key contexts, such as, location, time, priority, therapeutic, systems, education, prevention, value (economic), value (ethical)?

This particular web site and contents is predicated upon the HCM being of great potential in respect of health, education, environment and holism. It is time to extend this potential to young people, the importance of citizenship, critical thought and the future.

Holism is too important a concept to have one meaning, one context. Mogensen (1997) argues that within the holistic perspective of critical thinking:

'the holistic, insists that critical thinking involves both feelings and reason. It does not accept that thinking is to be understood as a purely cognitive and intellectual matter without emotions, feelings and intuitions. Critical thinking is human rather than mechanical.' p.434.

The (intractable?) problem remains of inherent parallelism in problem solving behaviour that appears sequential in practice. At a certain level people think in parallel, or have several processes running at once, which they attend to in turn. The appearance is serial (mechanical) action. How do nurses determine model selection? Do several cognitive strategies operate simultaneously - at the organisational and social levels? The tension between mechanistic and humanistic approaches mentioned previously is often interpreted as mutually exclusive. Nursing is either mechanistic or humanistic, but not both. A more accurate view undoubtedly is that:

Nursing* =	humanism	+	MECHANISM
* (and by implication all health and social care)

with information as a unifying concept, human reason as the unifying arbiter.

© Peter Jones 2000-2003

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