! See Also

Aims & Objectives

FAQ

HCM & Multicontexts

Interpersonal Links

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.

2. Finding Judy Norris' Nursing Theory Site in 1997 (which has a new address), prompted me to act. I had to do something.

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 theorists shows.

Working in adult community psychiatric nursing, and since 1992 with older people the HCM has functioned as an aide-mémoire - a check list. It also proves invaluable in writing and mapping genograms (family trees) of clients, helping to engage and elicit information from clients and carers. Whilst in some formal assessments I have used a page to record the identified key problems in their respective quadrants, and an outline plan, the HCM is not adopted within my organisation. When opportunities arise, however, I teach the HCM to students on placement in our unit.

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.

In the UK at least the politicians commandeered the slogan 'back to basics?' We need to remember that what aptitude is to engineering, so attitude is to nursing. Yes, practical skills are needed too, but the theorists can help keep us in touch with the caring roots of the profession.

The problem is that in talking theory it is all too easy to get 'carried away'. To digress for a moment, I would like to share with you my new model of psychiatry. A model called:

The selenographical co-longitude model uses the selenographical co-longitude of Sol (an alternate name for our Sun). The model is based upon the very foundations of human thought, and the questions that were posed when language first emerged. The model builds on contemplation, as our ancestors did when they scanned the heavens. Surely the ideal for a model of psychiatry! After all, how relaxing it is to contemplate the heavens. Alas, given the glare from civilization, apart from events such as comet Hale-Bopp, the population lack the time and opportunity to use contemplative therapy - to relieve stress. Now astronomy, the first of the sciences is all but lost to the developed nations, since it is now they that shine at night. With supermarkets open 24hrs and the threat of global warming the SCL model can predict much. A key component of the SCLM - is a return to humanities spiritual origins. What is the selenographical co-longitude of the sun? It is the position of the terminator - the point between day and night - on the lunar surface. So to put this model simply; as part of our health assessment we must ask - is it a full moon tonight?

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Seriously, returning back to Earth the original questions Brian sought to answer with HCM were driven by a desire to:

1. meet the needs for curriculum development and planning
2. ensure comprehensive assessment in child care -
3. and learning disability nursing

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:

1. physical
2. psychological
3. social
4. plus it adds a fourth: politics - autonomy

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

For example:

Past medical (science); psychiatric (interpersonal and social) histories.
Past employment and welfare entitlements (political and social).
Clients response to treatments - physically (science); psychologically (interpersonal); the families response (social).
Responses to prognosis; contingencies in the event of relapse, or crisis.

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?

Ever since the early 'Voyager' spacecraft simulations graced popular science programs in the 1970s and the on-going Martian escapades, the development and maturation of computer based visualization has been of enormous interest. Running the BBC micro through the night to produce fractal landscapes was fascinating, even though maths is a foreign language to me. The cliche has it that "space is the final frontier." The HCM proved a revelation, because I could mentally enter a terrain - sometimes smooth, sometimes jagged. Some parts would be empty, demanding to be filled.

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:-

1. Domain space (space devoted to, occupied by the subject matter of a specific discipline)
2. Problem space
3. E-Space ('E' = epistemology - the study of knowledge)
4. Nursing space
5. Care space

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:

'Health communication has no overarching theory from which to proceed, nor an exemplar of research. This lack of coherence is due to three conditions: the peculiar nature of the health care context, the vast range of communication phenomena to study, and the fact that communication has been studied from the point of view of other disciplines.'

Have things changed since Pettegrew & Logan made their observations? The numbers of therapies are thought to be in the order of 250 by London (1988) and over 400 by Norcross & Arkowitz (1992). What models and theories do occupational therapists, physiotherapists and social workers use? Management has its own set of theories regarding organisational behaviour and group dynamics. But there is no overarching theory that links them all (Jones, 1996).

Two key factors that prompted the development of nursing theory:

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:

• resource management
• quality of care
• outcomes audit
• patient charters
• purchaser/provider organisation
• clinical risk management
• clinical governance

- impose further demands on nurse educationalists and theorists. Effective and efficient coordination, communication and collaboration of the whole team is essential to achieve:

• comprehensive assessment
• continuity of care: (shift-to-shift - intradisciplinary) (discipline-to-discipline - interdisciplinary)
• discharge planning
• effective resource management - beds, clinic sessions.

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:

1. the set of all the nursing terms used in people's everyday language - patients, carers and nurses?
2. the terms used by nurses only - a sort of nursing Esperanto, not just for national use, but global too?
3. a formal computer based language that is compiled or interpreted as a computer program to carry out nurse (and other) health care information recording/retrieval tasks?
4. a formal specification or system which can be specified to suppliers as a requirement in the procurement of nursing and other health information systems.

Much effort has been spent on projects to produce digital thesauri of nursing terms:

• International Classification of Nursing
• READ Nursing Terms
• NANDA and other coding schemes
• TELENURSE
• and OTHERS

- all prompt a need for us to consider anew:

• new and established models of nursing AND health care
• the costs / benefits of the coding schemes NOW; not when they first started

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…

Table 1

* disarms yet empowers
* is simple yet complex
* local yet global
* applies to individuals and populations
* is neutral or activist
* is able to represent and disseminate
* engages and educates
* and transcends culture, politics, gender, beliefs and ethnicity.

© Peter Jones 1998

Thank you for your interest - please visit again soon.

References:

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:

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Copyright © 1998-2003 Health Career Model by Brian E Hodges.
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Copyright © 2004 Peter Jones
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