KEYWORDS: Structure, Model, Cognitive structure, Cadastre, Theory - Practice debate, Processes, Information ecology

Citing this page:

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

<>, Accessed

Introduction

Initially, planning this section on the assumptions behind the HCM, I was uncertain about how to proceed. This solution can be explained with resort to the fact that (cognitive or other) structures alone cannot explain the way members of the health and social care team reason about what they do. And still less how patients and their carers reason. The most obvious feature of the HCM is its structure, so the task here was divided between structure and theory. Structure and theory are inextricably linked. In order to explore assumptions behind the HCM, questions must be posed about how nurses and collectively the multidisciplinary team reason. The nursing and medical informatics literature provides evidence that this is not a novel endeavour.

If by 'reasoning' we are referring to people's ability to extract relevant information from the chaotic mix about them, then some selection, ordering, and sorting process must be at work. Decisions must be made about what to ask, what is relevant, what not. Some heuristic (rule) or framework must be used. This may be the format of an assessment scheme (I am thinking of global tools here, not specific assessments), with documentation or an e-form to fill in. Whatever they may be called - these cognitive structures, are important in imposing constraints on the search for, interpretation and deployment of solutions to information processing problems.

STRUCTURE

Structures can be physical such as those you can bump into on a clear sunny day, or they may also be conceptual, living in the mind, or represented on paper (or electronically). It is not surprising then that various process based formulations displaying a variety of structures have developed to assist nurses and health workers. The march of time and Governments with the constant stream of political, cultural and social changes continually challenge and test these processes and the structures in which they are thought to reside.

'Structure' suggests synonyms such as 'model', and 'framework'. Nurses have 'models of nursing' and the 'nursing process'. Health care workers seek to empower people by bolstering their existing problem solving solving skills, or helping to furnish new ones. The multidisciplinary team have looked for common structure in their multiple care inputs. They have found it in events and care pathways, formalized in integrated care planning. All the preceding examples plus - Single Assessment Process and Care Programme Approach are specific responses to manage data and achieve 'information ecology' the title of Davenport's (1999) text. Ecology, however, suggests balance, but sometimes this is not achieved automatically, especially in persons or systems that are immature.

"THEORISTS AND PRACTITIONERS BOTH CLAIM A HOLLOW VICTORY"

We continually get in a muddle about reality and our perception and representation of it. As philosophers and physiologists have established, even physical reality can be considered as symbolic. A representation of how things were 'x' milliseconds ago according to our senses. Of course, even then research by psychologists and our everyday experience informs that our senses can and do deceive us. Out of the total number of phenomena that theory could account for, in practice a compromise must be reached. Ultimately it is these relationships and debates that gives rise to the so-called theory-practice gap.

This gap extends from the philosophical realm - to how well students can transfer their learning from academia to clinical practice. Helpfully, for the HCM Larsen et al. (2002) challenge the very existence of a theory-practice gap:

It is obvious that almost everyone spontaneously experiences a gap, but the findings of our study indicate that there is no inherent gap between theory and practice. Theory and practice exist in their own right as 2 kinds of knowledge, theoretical knowledge and practical knowledge. This statement of relations between theory and practice challenges not only theorists and practitioners but also basic thinking in modern,Western cultural circles that has been in place since the enlightenment. The experience of a "gap" is a social construct; it is a product of history and culture. Larsen et al. (2002) p. 211.

There is a tendency to declare many phenomena as being social constructions. What implications arise from Larsen et al. and just how does their descriptive, qualitative, and comparatively designed study (p. 206) influence - help as suggested above - the HCM? Their conclusion suggests that at a meta-theoretical level, it may indeed be feasible to locate a space which we can populate with both theoretical (clinical evidence, health theory) and experienced practice (priorities, perspectives, problems, care and social goals and outcomes.

Nursing has for several decades been preoccupied with cognitive structures - models, conceptual frameworks, but before proceeding further, health care occurs in the real world, in real, physical structures. All activity - including nursing - takes place in space. Instead of looking for the bridge to span the theory-practice gap, perhaps we should be looking at the space in between?

SPACE: FROM STRUCTURALISM TO INSTITUTION:

what a web we weave

Structuralism continues to have a profound influence in the development of health care, ever since the pioneers of medicine centered on structure and function. Even a hundred years ago McNamara (1999) describes how it was commonly thought that the growing human embryo passed through all its previous stages of evolution. Physical structure and morphological transformation still perplex and fascinate today, but conceptual structures hold a unique fascination for human kind. This fascination is surely bound up within the varied forms of representation, which Peterson (1996) claimed were under investigated, despite their importance in computing, cognitive science and artificial intelligence. Has our understanding changed during these intervening years?

If at this point 'space' is considered literally as physical space, then space as a public resource is and has always been highly politicised (Klein, 2001). Hillier & Hanson (1999) provide novel perspectives for health professionals. In 'The Social Logic of Space' they highlight what community staff quickly realize. Entry into a building results in behaviour change. Whether entering a school, community health education centre, out-patient clinic, or a patient's home a persons behaviour changes. (Although accident and emergency staff have cause to wonder, when alcohol or drugs upset the expected norms of behaviour.) It is not only roles that can determine behaviour, but place too.

This point comes full circle with recognition of the need for community based - community services. Service modernisation is not only about personnel. The environments people live (residential care) and work in are crucial to attitudes, ethos and ultimately quality of service. Healthy patients need healthy staff and both need and deserve healthly hospitals.

Place - is as crucial a part of our orientation as person and time, and so fundamental to health and maintenance of well-being (Williams, 1998; Becker, 2003). (Clinical experience of the negative impact of house moves for older people prompted production of a website that cautions - 'Beware Reflex Moves'). Compared with homes, institutions such as hospitals (and prisons!) are 'reversed buildings'. In these institutional settings, power is altered as community staff are acutely aware. In hospital the subjects occupy the key 'unit' or 'space', be that a bed or prison cell. The staff - those with their autonomy and freedom intact - operate around them, on the periphery for limited (shift based) periods of time. In prison, the path to becoming a patient, that is having access to health care may be barred by rules, custodial practices, incompetence and of course environment (Stoller, 2003). Stoller cites Casey’s (1997) notion of anti-place.

Hillier & Hanson (1999) seek new theoretical methods for the use of geographers, architects, policy makers, anthropologists and sociologists. They capture most eloquently the orientation of their work:

'... perhaps contrary to appearances, human spatial organisation is not three-dimensional in the same sense that it is two-dimensional - for the simple reason that human beings do not fly and buildings do not float in the air. Human space is in fact full of strategies - stairs, lifts, etc., - to reduce three dimensional structure to the two-dimensions in which human beings move and order space. This is not to say that the third dimension is unimportant; only that it is not comparable with the two-dimensional structure. Buildings of more than one storey are two-dimensional structures laid one on top of the other and connected in a two-dimensional way. Human spatial organisation is, in effect, rooted in two dimensions and elaborated in three.' Hillier & Hanson (1999) p.27

Staying with spatial organisation is the realisation that the registration of boundaries (cadestre) so important at local, regional and international levels, must increasingly account for spaces above and below ground and also in 3D (Stoter & Ploeger, 2003; Stoter & Salzmann, 2003). Architecture is just one discipline with specialised information processing needs. Needs that are now taken for granted, and are applied elsewhere with appropriate modification. Specialist operations that were previously the preserve of research labs, have now given way to commercial programs that can import favourites or bookmarks to enable a 3D web browsing experience. As one commercial enterprise explains:

How much more refined and usable will these applications be in five years time? Having structures now - the bones; what ligaments and tendons can we attach tomorrow? When we stand back and look at the spaces our structures (physical or abstract) create, Rezzonico & Thalmann (1996) observe that:

'The problem is that a 3D scene has to be generated from data which a priori has no correspondence with real physical space. Any spatial configuration that we choose will be arbitrary. Nevertheless this is not new. A similar problem appears when dealing with a file system and trying to give a user friendly view of it.'

The space created within the HCM is not accidental. Brian's selected axes individual-group and humanistic-mechanistic are not arbitrary. Their use is predicated on their ubiquity for health care workers. The space created must incorporate the rich variety of experiences and phenomena that people encounter in health; be they speech therapists, doctors, policy makers, advocates, patients, mums to be, or whoever. Alternate formulations are of course possible and may be used in other disciplines(?).

Knowledge (or lack of it!) differentiates the space afforded by the HCM. A classic example being novice health workers, learn from their expert colleagues (senior and junior), patients and carers. Novices have to acquire their own 'cognitive maps'; maps that experienced colleagues possess and must themselves constantly update.

SCALE FREE NETWORKS

Structurally, a map is a network. A traveller may not need to know in detail all of the locations (nodes) on the map, but local (expert) knowledge is crucial. Specialist knowledge is now routinely captured in expert and decision support systems, semantic networks can support clinical coding and classification tools.

Buchanan (2002) and Barabási (2002) identify networks as permeating our lives in ways not previously considered. They refer to scale free networks found in an incredible range of phenomena. One example, publicised in the media shows how despite a population of over 6 billion souls upon this planet, there can be relatively few connections between people. This led to formulation of the so-called Bacon number and game. Introducing a chapter - The map of Life - Barabási makes it clear that focusing on biology (genes) is not enough. In the late 1980s a flurry of discoveries were announced relating an illnesses to a specific gene. Using bipolar disorder as an example, evidence implicating chromosome 11 was produced, but studies followed showing that chromosomes 6, 13, and 15 were also involved. p.179-180. Barabási declares: 'If we want to understand life - and ultimately cure diseases - we must think networks'. p.180 (The age of postgenomic biology beckons?)

The importance of networks extend to languages. For languages to work words must have a certain distance from each other, this property makes possible such applications as semantic networks, information retreival and knowledge management. A sort of lexical cadestre. Two examples relate concepts using web media to display the results. Try typing a word - such as 'care' - into Communication Concept Explorer (beta). I am currently exploring Compendium brought to my attention by ITForum, which:

- is the semantic hypertext concept mapping tool at the heart of the Compendium methodology. It is the result of over 15 years' continual research, deployment and development of a tool to support the real time mapping of discussions in meetings, collaborative modelling, and the longer term management of this information as organizational memory. (Compendium website: Accessed 28 Jan 2005)

It is interesting to try, but not easy to read Alice in Wonderland using TextArc. Our Sciences domain links provide these and more examples.

STRUCTURE and HODGES' HEALTH CAREER MODEL

What do networks mean in terms of the HCM's structure? Perhaps, each knowledge domain within the HCM can be described as a small world network. Several key concepts (problems) act as universal primal hubs, acting upon and responding to each other positively and negatively as modelled in a neural network. Before this assumption is accepted, and there is a wealth of theory to support this view, we would need to establish the viability and consistency of the HCM's structure.

The most striking feature (for me at least) of the HCM is its structure. For the HCM to have meaning and clinical validity, however, there must be some basic rules, theoretical assumptions underpinning its construction. Not only construction, but the final structure and ultimately its application. For example, once populated, how do the quadrants relate to each other? Where (quite literally) - are the boundaries? Are these fixed, or dynamic, consensual or individual?

A pivotal assumption behind Brian's work is the skill of the assessor. Namely, the ability to identify and place health care concepts and other relevant data onto a conceptual framework.

Whilst the HCM can be described as an elaborated checklist, this framework can also be described as a problem space. A simple construct created by the placement and naming of HCM's axes. The axes Brian employs are not exceptional. We all encounter individuals; groups; humanism and mechanism on an everyday basis. What is exceptional are the questions these axes - or more properly 'continua' - provoke. Especially once they are transcribed to paper. Once committed to paper, black(white)board, flipchart, care plan, or visualization program, their structure takes on an explicit form and is more readily revised and shared with others.

Points along the continua could denote many things - relationships; contexts, concepts - problems priorities, but can the continua be used and 'read' in this way? Can we say, for example, that -

	One social concept 'family' is more humanistic than another 'law'?
A scientific concept such as time is more 'mechanistic' than another - 'digestion' for example?
	That self-esteem is less of an individual concept than self-image.
That basic services such as water, electricity are more political than personal finance.

If, as I propose the future potential of the HCM resides in supporting health (and other?) informatics solutions, then its conceptual structure must be represented within a computer (whether workstation, PC, tablet PC, laptop, or PDA). Health informatics has already 'been there and done that' in terms of representing highly complex conceptual frameworks and knowledge domains . But using examples from my own clinical background of mental health, elaborated structures may be needed to represent:

• time - change;
• categorization - in truly multidisciplinary environments;
• feedback loops; as per sequential diagrammatic reformulation.
• iteration - (nursing - health care process);
• complex process architectures -
  (integrated care pathways; care program approach; case management, single assessment process)?

The public sector is a highly mechanistic bureaucracy (Mintzberg, 1983), to an extent it has to be. Now however, many of the reasons for its ponderous, clanking gait are historical. Despite ongoing efforts, in HCM terms the horizontal (humanistic-mechanistic) distance of the organisation management and clients should be much less. I can speculate that the vertical (individual-group) distance has reduced with the demise of many middle management posts, but further change is needed. The (UK) trend to merge (rationalise) health and social care functions provides two opportunities:

1. to close this distance structurally (but widen it theoretically - if that does not seem a contradiction)
2. to further increase the relevance of the HCM, by staff integration and the single assessment process (SAP).

The SAP presents a key application area for the HCM. Of four assessment types in the DoH's guidelines:

1. Contact assessment (including collection of demographic information)
2. Overview assessment
3. Specialist assessments
4. Comprehensive assessment

- are there any that might be supported by the HCM? At the time of its conception in the 1980s, Brian emphasised that the HCM is not prescriptive as to the philosophy of care, or model of care (nursing) that is adopted. In a similar fashion, the HCM need not dictate the particular assessment tools employed. Rather, it can provide 'views' on the recorded data, imposing structure as many information systems offer within their menu systems. Once the SAP is completed (or at an appropriate juncture), the output could resort to the structure of the HCM for reporting.

So perhaps the overview and comprehensive assessments are within the scope of the HCM? More than ever the MDT need a 'common (reporting) currency'. Why not provide them with one, using the HCM? It may be possible that this currency can become a standard across the borders into social services and primary care, the private and voluntary sector, reassuring patients and carers who hold this summary of their health care profile. Why stop there? Like the Euro, a health currency is needed between nations, and efforts to achieve this telematically are ongoing.

These efforts are vital, but may be equivalent to finding solutions to the technical problems. What is needed are solutions to the social, humanistic difficulties. In a sociotechnical world you cannot have one without the other. Of course you can, but doing so creates waste, disillusionment, complexity and organisational instability, fragmentation. By organisational instability and fragmentation, I mean short-termism, no time to consolidate, study the impact of actual / proposed changes, and a reduction in the number of personnel who appreciate the bigger picture. If (as befits human capacities), no single individual has the 'big picture', then surely a reduction in the number of people who approximate this capability, has a negative impact. Is it this problem that prompts calls for joined up policy and politics?

Crudely put, in the search for increased productivity pressure to continuously apply the 1/2 x 2 x 3 = P equation Handy (1994), must ultimately lead to diminishing returns. For example, make organisational structures more complex and other structures are likely to mirror this trend.

Image: John Langdon

OF HYBRIDS & CYBRIDS

These questions demand more than consideration of structure. New ICTs continue to be deployed in health and social care, which need expertise to maximise return on the investment. As personnel already wear several hats, who can adopt this adornment? In the 1980s 'deliverance' was vested in hybrid managers. The 1990s brought 'NCEs' - 'New technology executives' Bicknell (1996). Senior officers with the combined management acumen and ICT awareness to make organizations the dynamic and responsive enterprises they need to be tomorrow.

Amongst the data warehouses, executive information systems what structures will these hybrid managers use? Managers of increasingly virtual organisations will use virtual data. One form of elaborated structure may be what David Gelernter (1998) refers to as a 'cyberstructure' - a term he coined as an:

'assemblage of information floating in cyberspace. An 'assemblage of information' means a collection of data items arranged according to some agreed scheme.'

Do we have a scheme in the HCM? Gelernter's key point is inclusion of 'agreed'. It will be interesting indeed to watch how MDT working evolves, as (in my humble opinion) health and social services have still to scratch the service (pun intended!) in collaborative computer supported working. Beyond this website, itself a cyberstructure, could the HCM be implemented as a cyberstructure? Part of an individual's information space designated as personal? Accessed by the MDT, only with permission of the named individual or their guardian, this permission being implied, upon referral to or within health/social services.

A crucial point that must be made is the contrast between our dependence on the paper based record, and the ever developing ICT/graphical options. How readily can this transposition take place? What is actually involved?

We can represent what is really quite obvious when viewing our use of paper in 2D and the more complex 3D spaces people inhabit (cognitively or physically). The image shown below takes us from a basic undifferentiated, empty 2D plane at top left, and below its cubic counterpart; to a blank 'page' partitioned (in this example) with the HCM quadrants; to the 2D 'page' filled with information. The 3D equivalent is shown above, filled with abstract shapes, these could readily be concepts, such as, care problems which when clicked upon open to reveal finer detail or associated concepts. The 3D form shown here therefore is not elaborated, it is merely illustrative.

Before leaving structure for the none too distant realm of theory, surely exponents of HCM are being seduced by the temptations of our particular information age?

• Seeing everything, but understanding little or nothing!
• If all seems lost - add another dimension (or two, or ten!) Brian added order and chaos in his final unpublished version of the HCM, which may yet bear fruit.
• The "map is not the territory" - often quoted in therapy discussions.
• Metaphor - there are limits to what we can do with metaphors.

According to Cunliffe’s (2001) book on the voyage of the ancient Greek explorer Pytheas, early mariners navigated using a text called a periplus. This provided the first recorded observational views of the world, describing coastlines by landmarks, winds and local conditions. h2cm is a periplus for learners, an aide memoir and reflective tool; a space to place those initial sightings and personal experiences.

The model provides placeholders for knowledge. Exactly where these are placed cognitively and how they are revised is a subject to on-going research. Health practitioners have for millennia debated the status of ‘caring’ as a science and/or art. H2cm demarcates the boundaries of disciplines. The distance from the coast to the nexus of the care domains denotes the journey from beginner to expert, a journey that people will hopefully be prepared to repeat by new routes at regular intervals: life-long learning.

This brings us to questions about theoretical assumptions.

© Peter Jones 2000

References:

Barabási, A-L. (2002) Linked: The New Science of Networks; Perseus Publishing, Chap.13.

Barkhi, R. (2002) Cognitive style may mitigate communication mode, Information Management, 22, 677-688.

Becker, G. (2003) Meanings of place and displacement in three groups of older immigrants, Journal of Aging Studies, 134: 1–21.

Bicknell, D. (1996) Why executives must prepare for a new role; Computer Weekly, March 7.

Buchanan, M. (2002) Small World: Uncovering Nature's Hidden Networks, Weidenfeld & Nicholson.

Casey, E. (1997) The fate of place: A philosophical history. Berkeley: University of California Press.

Cunliffe, B. (2001) The Extraordinary Voyage of Pytheas the Greek, Penguin.

Davenport T., Prusak L. (1997) Information Ecology: Mastering the Information and Knowledge Environment, Oxford University Press.

Gelernter, D. (1998) The Aesthetics of Computing, Weidenfeld & Nicolson, London.

Handy, C. (1994) The Empty raincoat: Making Sense of the Future, Hutchinson, UK.

Hillier B., Hanson J. (1999) The social logic of space, Notes Chap 2, The Logic of Space, CUP, p.272

Klein, N. (2001) No Logo, Flamingo.

Larsen K., Adamsen, L., Bjerregaard, L., Madsen, J.K. (2002) There is no gap `per se' between theory and practice: Research knowledge and clinical knowledge are developed in different contexts and follow their own logic, Nursing Outlook, 50: 5, 204-212.

McNamara, K. (1999) Embryos and Evolution, Inside Science 124, New Scientist, 164, 2208.

Mintzberg, H. (1983) Structure in Fives, Prentice-Hall, Englewood Cliffs, NJ.

Peterson, D. (Ed.) (1996) Forms of Representation, Intellect Books, Exeter.

Rezzonico, S., Thalmann, D. (1996) Browsing 3D Bookmarks in BED, Proc. WebNet 96, 574-575.

Rush, K.L., Ouellet, L.L. (1993) Mobility: a concept analysis, J. Adv. Nurs.,18,486-492.

Stoller, N. (2003) Space, place and movement as aspects of health care in three women’s prisons, Social Science & Medicine, 56: 2263–2275.

Stoter, J.E., Ploeger, H.D. (2003) Property in 3D—registration of multiple use of space: current practice in Holland and the need for a 3D cadastre, Computers, Environment and Urban Systems 27.

Stoter, J., Salzmann, M. (2003) Towards a 3D cadastre: where do cadastral needs and technical possibilities meet? Computers, Environment and Urban Systems, 27, 395–410.

Williams, A. (1998) Therapeutic Landscapes in Holistic Medicine, Soc. Sci. Med., 46:9,1193-1203.

top : home