Care pathways: 15 minutes on Monday - how far is that?

On Monday I have a quick visit for 15 minute slot on care pathways at an interprofessional study day for 2nd and 3rd year students.

After the short presentation I'll ask the question of what difference the students can make to the patient's care pathway. There may be value in continuing the 'journey' metaphor?

They can ensure the care pathway is well-documented (otherwise it doesn't exist, and travel on it never happened) they can check it is accessible (an achievable goal) and that it does not trip anyone up (we don't do - iatrogenic).

There are further tests: is it navigable, tried and tested, a safe (evidenced-based) route? As the student's contemplate a major step in their health career, we really need them to focus on the health career of the persons in their care.

[ There won't be time for this: but do we need to wait until the 'end' for the outcome and capturing that (feedback). Or can do we this verbally, incrementally (positive impact on quality)? ]

I could ask them all to stand and make like sign-posts, but for the risk of poked eyes. It's true though, sign-posting is an important job, but how we do that is another post (the value of self-discovery as learning).

Once medically fit the key thing should be checking the person's (not viewing them totally as patient) wayfaring skills.

OK, who took my care pathway?

Can they read the map (are they health literate)? Can they find a map? Do they have a stay-well, recovery and well-being ... compass (a conceptual framework, an app, care plan)? If there literally is no self-care pathway under the patient at present, then the student can help them and their carer if necessary to find or create this compass - across the required care domains.

THEN this person (potential future patient) can avoid having to step off their self-care pathway and onto the health care pathway. You see there's a risk and a cost in that particular transfer.




Image source: http://www.farlandgroup.com/customer-journey-mapping/

Resistence is futile: give in to the obvious need for the 'nhm'

INTERPERSONAL : SCIENCES
humanistic ------------------------------------------- mechanistic
SOCIOLOGY : POLITICAL

individual

nhm	ohm + nhm
nhm	nhm (+ ohm!)

group - population

ohm: The ohm (symbol: Ω) is the SI derived unit of electrical resistance, named after German physicist Georg Simon Ohm. (Wikipedia)


nhm: The nhm (symbol: +).

However, the principles do not extend to problems posed by cognitive impairment as a result of the illness and the ever present danger of wandering, seeking old and familiar surroundings, or acting on memories from years gone by. Some patients become aggressive at times; the service must have mechanisms for managing patients effectively in ways that recognise their inherent worth and humanity. The stigma and abbreviated autonomy that is implied in managing people with dementia requires a new holistic method of managing their care that relates the care to the patients'/service users' values. p.80. [my emphasis]

Heginbotham, C. (2012) Values-Based Commissioning of Health and Social Care, Cambridge, CUP. (Review to follow).

H2cm - Beauchamp and Childress (1994) four principles of healthcare ethics

I'm clearing the decks of books at the moment, one of which is McGonigle and Mastrian's Nursing Informatics and the Foundation of Knowledge, Second Edition (2012). I notice a 3rd edition is in preparation.

A review will follow, but in chapter 5 on Ethical Applications of Informatics on page 73 (pb.) the four principles healthcare ethics of Beauchamp and Childress (1994) are mentioned in a very concise, informative discussion.

Although the exercise that follows involves 'putting concepts in boxes', doing so helps us to see beyond the boxes, to see the links between.

Although harm takes several forms it is physical harm (for nonmaleficence) that is most commonly thought of. This is the ethics concerning an individual so why have I placed beneficence in the sociology domain? Justice should be straight forward, but only if reinforced by law, and then only if that law is exercised. Autonomy should be straight forward. I must have the mental capacity, the insight to have choices. In the eyes of others these choices may be rationale or irrational. Although justice is place in the political (group / population) domain, rights are ascribed to individuals. This is useful property of Hodges' model the way that the individual and their mental life are diametrically placed (opposed?) and linked. It is others who are having determine the ethics of a given case, evaluating what is in the person's best interests; also having to take into account any advanced directives, or living wills.

What do you think? If you have some comments, can improve this or feel there is a correspondence here please let me know.

INTERPERSONAL : SCIENCES
SOCIOLOGY : POLITICAL

individual

autonomy	nonmaleficence
beneficence	justice

group - population

• Respect for autonomy - the patient has the right to refuse or choose their treatment. (Voluntas aegroti suprema lex.)
• Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.)
• Non-maleficence - "first, do no harm" (primum non nocere).
• Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality).

Above text:

http://en.wikipedia.org/wiki/Medical_ethics

Hodges' model 'Always Waiting' with Michael Kiwanuka

Seeing and listening with Hodges' model:

INTERPERSONAL : SCIENCES

SOCIOLOGY : POLITICAL

	Safety, 'Illness', ...?
LIFE HISTORY, several selves, ...?	LIBERTY ...?

End of Life Care (Pathways), Nursing and Thresholds

There is a controversy (Telegraph) that has been growing for some time, concerning the Liverpool Care Pathway for end of life care. This is a very demanding and yet rewarding aspect of nursing. I have experience of end of life nursing care in a non-specialist capacity, having worked on wards for older adults and being involved with people who have mental health and life-threatening physical health problems.

It pains me greatly not just as a scouser that something with 'Liverpool' in it should become a cause of distress, a center for debate and review. Is the pathway green and shady? Is it comprised of stepping stones, with room for two, and with time granted for your next step? Or is there a danger in some instances the path can become tarmac clad, without the succor of a services stop for basic sustenance? Can a pathway become a motorway? What does that sign say? "DON'T HOG THE MIDDLE LANE!"

What pains me seriously is that what can be a invaluable, evidenced based palliative care resource can be undermined due to the complexity of the generic and palliative care situation.

If we truly practice person-centered care then there are no care pathways.

Or, to put it another way: there are as many care pathways as there are patients and carers.

Whether you believe in social medicine, or private; whether you are laissez-faire, or leave such matters to a higher power there is no escaping the need for organisation - for order.

The mix and concentration of people, knowledge, resources and time dictates that tasks, roles and processes be delineated and assigned. We need to assure a given level of quality, and to predict things, not everything is as difficult as the weather: or death. Pathways can assist in specific contexts.

Is there scope for personalisation on a pathway? ...

Steps and pace can vary and to the left and right of center. There are many pathways though: some valid - evidenced, award winning; while others might be broad, narrow, twisted - to become a disorientating ethical loop...

Being placed on a pathway denotes a decision point, a threshold. We need to remember in all fields of health and social care practice that there are multiple thresholds to be taken into account, communicated effectively and revisited:

INTERPERSONAL : SCIENCES

SOCIOLOGY : POLITICAL

'me' - existence, resilience, assets, personhood, ethics, personal values, mood, personalised care, understanding of treatment, communication skills, self-expression, loss, orientation, observation, distress, psychological assessment, sedation, beliefs, choices, :theology PURPOSE	'me' - existence, feeding, nutrition, fluids,  evidence base, Liverpool care pathway, quality of life measures, referral thresholds, prediction, resilience, reductive - holistic assessment, medication, distance, where: home-hospital-hospice? pain management, decision locale, specialism, basic nursing care, resilience PROCESS
memories, good-byes, love, compassion, carer under stress, reassurance, counselling skills, meetings with family, empathy and rapport, patient and relative engagement, life history, relative's recognition that loved one is dying, care strategies,  patient experts, patient - carer experience, communities of PRACTICE	consent, advocacy, mental capacity,  integrated working, effectiveness, independent autonomy, service access, bed availability, health & nursing in the media, scope of nursing, scope of medicine, law, medicolegal issues, whistleblowing, complaints, formal review, appeals, organisation, argumentation, professionalism, ageism, POLICY (re-PURPOSED)

The relative position of concepts above does not indicate priority.

"The LCP is not the answer to all our needs for care of the dying but is a step in the right direction."

Marie Curie Palliative Care Institute
Liverpool Care Pathway for the Dying Patient (LCP)

Hodges' model in Murphy & Welford (2012) Agenda for the future: enhancing autonomy for older people in residential care. Int. J. of Older People Nursing

ABSTRACT: This is the concluding paper of a three paper publications. Paper 1 focused on specifically understanding what autonomy for older people in residential care means. Paper 2 discussed the various factors that either facilitate or hinder residents autonomy and directed readers to reflect upon their practice. This final paper outlines the findings from the action research phase of a study aimed at enhancing resident autonomy. It describes just one way in which residential care units can work on enhancing residents autonomy and enables the reader to reflect upon nursing practices, which with the right approach can be resident-centred.

Murphy and Welford write:

Hodges (1997) model is essentially concerned with the person (resident) in a social context. The notion of it derives from the intervention of the nurse being future orientated, increasing the health choices, health chances or health prospects of individuals or groups (including families) taking cognisance of the biography of the person or persons being helped. The person already has a biography that has been influenced by their physical and psychological make-up, the kinds of families and social networks they have experienced and the culture or geographical location in which they live. The nurse then is also influenced by personal factors of their individual physical or psychological origin and factors relating to their social world and the policies that govern their daily life. The nurse (assessor) must take cognisance of the attributes the person (resident) brings with them in their current presentation (problem) and how this affects their future choices both in terms of ability to make them and the range of choices available. Thus, this approach to care planning recognises the importance of negotiating care.  (online source - see doi link below)

I am not just very grateful to Murphy and Welford for their adopting Hodges' model in their study, but this supports my own use of the model in teaching staff about person-centred care and communication skills in residential and nursing care homes. The inclusion of a political domain and individual and group (populations) dimensions is a great asset in this context. Their conclusion also identifies the limitations of individually directed change, something that seems apparent from my own experience in nursing home liaison.
 
Murphy, K., Welford C. (2012) Agenda for the future: enhancing autonomy for older people in residential care. International Journal of Older People Nursing. 7, 75–80. doi: 10.1111/j.1748-3743.2012.00309.x

International Women’s Day

Some links for today:

Africa’s Girl Power

Women at the Forefront of AIDS Vaccine Research

Helping Adolescent Girls is Key to Women's Empowerment

What Does it Mean to be a Woman in 2012?

On International Women’s Day,
Protect Women Human Rights Defenders ...

Newsweek's 150 Fearless Women - 10 Supported by Front Line Defenders

Sources - as above and ...
HIPnet
Educate Girls in Africa