Brian Hodges' Notes on HCM:

Relating HCM to theory and practice

Health Career and the Curriculum

Some questions to facilitate both care and curriculum planning
• What possible interventions would enhance the health career?
• What knowledge would support the possible intervention?
• What knowledge of the NATURAL SCIENCES/ PSYCHOLOGY/ SOCIOLOGY/ HUMAN
ENVIRONMENT will illuminate the nursing observations?
• What knowledge of the NATURAL SCIENCES/ PSYCHOLOGY/ SOCIOLOGY/ HUMAN
ENVIRONMENT will support the nursing interventions?

Possible Nursing Interventions

Instrumental
This includes, for example, the use of instrument, appliances, techniques or schedules that have the
potential to be administered impersonally

Interpersonal
This involves the use of the personal attributes of the nurse in a therapeutic context

Educational
The use of educational methods to achieve change of facilitate the development of the health career

Organizational
In this situation the nurse is not directly involved in the care but enables optimum health career
development through referral to others, ensuring that others undertake the tasks or by such things as the
timing (or location) of clinics.

The essential feature of the health career model is the person in a social context. The person having
physical attributes that are explained by the natural sciences, and behaviour that is explained by
psychology. The social context was considered to consist of the social world explained by sociology and
the policies that structure the social and physical world.

The model consists of three layers: health career on the top, subject as the base, with nursing being the
intermediate and mediating layer between the person in terms of the Health Career and the Subject
disciplines.

The base layer consists of the four subjects:

• natural science;
• psychology;
• sociology;
• and politics.

Nursing is quintessentially future orientated and concerned with the person in social context. Intervention
including education, counselling or information needs to take account of the physical attributes of the
person - the presence of for example physical disabilities or aberrations and other attributes that may
impinge on health - or psychological attributes in terms of education, motivation, beliefs, attitudes,
personality of the person or in terms of group psychology - relationships the dynamics of the family or
network of friends.
In social terms the nurse needs to take cognisance of the norms, values roles and social pressures that
relate to such things as social class and the influences of particular cultures and sub-cultures on the
concept of health the approaches to health measures and the use of health services.

Health care without politics is simply not possible. Nursing occurs within a framework of policies that
need to be understood if not challenged. Accessibility of clinics, provision of materials, the ethics of any
intervention and the general allocation of resources, including the practitioners own time, all fall within
the political arena of policies that shape the human environment.

All nursing situations are essentially concerned with a particular person within a particular social context
of geography, time and culture. That the biography of the person (and the family) need to be taken into
account in the planning of the intervention makes the health career model particularly apt.

An examination of the contributing factors in various nursing situations has been undertaken.

Health Visiting
In public health nursing or Health Visiting it is possible to consider, for example, the contributing factors
to immunization practice, they physiology of immunity and the biological effects (or possible effects) of
non-compliance, the beliefs people hold about immunization or the motivation to participate in health
programmes, the social factors that influence uptake - social class, social press, values, norms - and the
effects of culture and the political arena of who is immunized, the policies that dictate control
immunization programmes, the power utilized by nurses who expect compliance, and the ethics of
immunization programmes.

Similarly it is possible to examine the physiological psychological, sociological and political aspects of
health education, child abuse, screening well man clinics, family visiting or other public health nursing
activities.

Intensive Care Nursing

In Intensive Care for example the nursing situation is complex involving a patient, significant
technological presence, and a `family'. The family (and the machinery for that matter) are not mere
appendages to the patient but constituent parts of the total nursing situation. The model states that at the
time of the nursing intervention the person already has a biography that has a controlling influence on the
health status, future pattern of health and, importantly, the nature of the nursing intervention. The
biographical health career extends backwards in time at least as far as conception up until the now
moment relating to the personal and social factors that impinge on health, they physical and
psychological dimensions of the person and the social and political aspects of the world in which the
person lives. In the Intensive Care Unit the immediate concern is with the recent Renal Transplant.

Both of these situations are related to the persons biography. Although the full health career will need to
be examined by nurses at some time before the patient is discharged from nursing care the nurse in the
Intensive Care Unit is required to consider in particular those aspects of the career that impinge on the
current nursing demand; considering and discounting rather than overlooking those areas of the model not
of direct relevance. The immediate social context is the intensive care situation itself, the intermediate
social context would be the 'family' (or immediate caring network) and employment; the wider social
context being the personal geography social networks, political scenario and the contemporary state of
knowledge. The patient (or client which may not be the same) is thus set within a particular space-time
framework. Some nursing activities have priority in terms of time or in terms of proximity.

District Nursing
In District Nursing the contributing factors to incontinence, ageing, handicap and disability, the problems
of sensory impairment, bereavement, or even the ubiquitous leg ulcer could be undertaken.
The use of the Health Career Model for the nursing care of the elderly not only indicates the usefulness of
the model but, importantly, clearly shows what nurses in this speciality have always know; that care of
the elderly is intrinsically interesting. Care of the elderly is interesting from a physiological,
psychological, social and political point of view as is evidenced by the quantity and range of research
undertaken in this arena.

The elderly are of special interest as they have a longer pre-nurse contact health career. By virtue of their
age they have had longer to acquire particular beliefs, values and habituated behaviours. Similarly they
are likely to have experienced a number of changes in the explanations for disease and other processes,
and to have been exposed to varieties of health care provision.

Community Psychiatric Nursing

Community Psychiatric Nursing is essentially concerned with the person in a social context. The nature
of persons and the specific social context may require further exploration but there is in essence no
disagreement between the role of the CPN and the Health Career Model. Whilst there may be different
goals for nursing interventions and different solutions to the same nursing problem, there is no
disagreement that nursing is future orientated and positively directional. Consideration of the Health
Career Model should assist the Community Psychiatric Nurse in the selection and evaluation of
intervention strategies.

Alcohol related problems are a common reason for referral to the Community Psychiatric Nurse. Alcohol
has recognized and well documented physiological effect, moreover, physical methods of treatment are
possible. To be in a position to help people with alcohol related problems the nurse needs to be aware of
the physiological effect of alcohol and to be an effective advocate of the patient the nurse requires a
working knowledge of the physical methods of treatment their uses, abuses, advantages and
shortcomings. Additionally the nurse should be able to speak with authority on the debate concerning
physiological dependence on alcohol. This would accord with the 'scientific aspects of nursing' as set out
in the Health Career Model.

Where physiological explanations are eschewed psychological determines may be substituted. Personal
inadequacies, personality, social skills shortfall, or family dynamics may be used to explain the
difficulties that result in the excess use of alcohol. The solution to the problem may be sought by
behavioural therapy, individual or group psychotherapy, social skills training, family therapy, counselling
or health education. The interpersonal aspects of nursing corner of the model would cover both the
explanations and the interventions and assist the nurse in identifying the knowledge that would support
the nursing strategy.

'Sociological aspects of nursing' are an important consideration from the norms and values that surround
the use of alcohol in different cultures, social classes or occupations to the medicalization of alcohol
related problems, the attribution of patient status and measures of social control. Such knowledge should
assist the nurse in the adoption of appropriate nursing care or the elimination of inappropriate strategies
where the most useful form of intervention is uncertain.

The remaining quadrant of the nursing component of the Health Career Model is `political awareness'. In
relation to the situation under consideration, alcohol related problems, `political awareness' takes into
account the services provided for people with such problems, the benefits to which they are entitled or
perhaps should be receiving, the ethics of intervention, the power relationships that occur between
professionals, the family and the client, and the legal aspects of nursing care. In addition the nurse should
consider the relationship between the `alcohol industry', the consumption of alcohol and the role of the
Government who takes taxes whilst at the same time promoting a campaign to combat the undesirable
effects of alcohol consumption. The debates surrounding the campaigns about alcohol abuse and drinking
and driving are illustrative of the need for nurses to be politically aware.

The Health Career Model could be used to illustrate other nursing situations that are the concern of the
Community Psychiatric Nurse. The model has been used in the planning of nursing are in community
settings and in the production of a curriculum based upon the English National Board Course Number
811, 'Nursing Care of Mentally Ill People in the Community' and subsequent courses.

Occupational Health Nursing

The model is concerned with the life of the person and how the various components of that life are
organized and interwoven. This requires a knowledge of the culture including (especially for the
Occupational Health Nurse) a knowledge of the nature of work patterns and practices. The reflexive
nature of the Health Career Model, together with the health orientation, makes its use in the very different
working environments likely to be encountered by and Occupational Health Nurse particularly apt.

An examination of the contributing factors in various Occupational Health Nursing situations may be
undertaken. It is possible to consider, for example, the contributing factors to accidents including
scientific aspects - age, gender, physiological explanations, use of equipment, control procedures or shift
patterns - psychological aspects, in terms of education, specific training, predisposing behaviours or
group membership. The sociological dimension of accidents could be examined in terms of values (risk
of injury versus possibility of bonus), traditional working practices or group norms. The political aspects
would involve a consideration of such things as rules, procedures, design and legislation that are intended
to reduce the incidence of injury.

Similarly it would be possible to examine the scientific psychological, sociological and political aspects
of specific working situations - examples being the use of visual display units, the sodium plant at ICI, or
the fermentation rooms of Boddingtons' - and possible the effects of such working environments on the
Health Career of the employees. Of course wherever people venture, nurses will be needed as well as
models, and theories of nursing care.

The Health Career Model facilities the setting of priorities as it does not demand specific information nor
does it demand the prior identification of problems or needs asking only that the situation be examined in
terms of what the nurse needs to do to enhance the health career and what knowledge the nurse is
required to possess in order to act.

The importance in all cases is to examine the nursing situation rather than the medical diagnosis.
The Health Career Model is essentially concerned with the person in a social context. The model differs
from other conceptual models of nursing in the consideration of the situation as a whole rather than the
person as a whole adding a new dimension to the term holistic. The model being situations in which other
models appear to have limitations.

The Health Career model does not differentiate between the knowledge a nurse requires to act (commonly
called theory) and the act of nursing (commonly called practice); the curriculum model should also be the
practice model. Neither does the model demand the acquisition of another language but instead requires a
questioning reflexive approach to nursing care.

You can now also explore how HCM can assist capture of the multicontextual nature of health and
nursing care delivery