Joumal of Advanced Nursing,

1992,17,1350-1354

Nursing models in a special hospital: cybernetics, hj^erreality and beyond Tom Mason BSc(Hons) RMN RNMH RGN Charge Nurse

and Mark Chandley RMN Staff Nurse, Ashworth Hospital, Maghull, Merseystde, England

Accepted for publicahon 3 March 1992

MASON T & CHANDLEY M (1992) Joumal of Advanced Nurstng 17,1350-1354 Nursing models in a special hospital: cybernetics, hjrperreality and beyond Two emerging themes that resulted from research camed out in a special hospital on the use of nursing models are identified The first theme to emerge was the tendency of the subjects to perceive the models as concrete enhties thus undergoing a process of reification The second theme identified w^as the adherence to the models outside the contextual nature of the setting which limited their effectiveness A theoretical framework in which to locate the results of the study is explored using cybernetic learning theory and the notion of hyperreality, using the works of Jean Baudnllard A method for innovation and changing practice in the speaal hospital settmg is suggested INTRODUCTION _., f , , 1 1 . 1 1 The use ot nursing models m a special hospital has , , J I . L . f i L j i o - v L been analysed both in terms ot extant models that have . J r . j . i f .1 /Hi . onginated from outside the forensic sethng (Mason & /-u ji -innn \A o r, LL ,r./^/,\ J 1 L Chandley 1990, Mason & Patterson 1990) and also, to J J 1 .1 • • J .L .1 1 some degree, models that are grounded withm the speaal u L 1 L If m lj -.r>o-.\ T-L I » L i_ tu hospital itself (Baldwm 1983) The bnkage between these , , L L LL I Li_ L f.i two approaches appears to be that the roots of the nursmg J , ., . 1 .1 11 ,1 , ,1 models that are used m the speaal hospitals onginate m the 1 L L c i_ 1A7U LL L L .^L ' 1 1/ wider context ot soaety Whether it be the cosmological 1 I fn /XA e D 1.1. ,r.rvrt\ 1.L ' L L model of Rogers (Mason & Patterson 1990), the activihes c 1 1 , t i ryt o /-L ji ,r>,^rt\ ot everyday living model (Mason & Chandley 1990) or J.L '

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the moral-retnbuhon model (Baldwm 1983), the genea, If J L. L, i. \c r\c 1U . logical toundahon is soaety ltselt Ot course, there is no , , , , , , , , ,, ., reason why this should not t)e so, as special hospital . ,

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to affect pahent care due, m part, to the fimdamental dichotomy between the sick-role adophon of voluntary , , , , • i i • .• , patients and those oi the compulsonly detained Also, the , ,, „ i i , i i , ^ • models methcacy was believed to be due to the fact that , f i i i j i • i • the notion ot value, inherent m the models, was devalued , , , , , , , , Py the contextual nature ot the speaal hospital setting , • . , , , , , , , wtuch dealt with a large pnson population who did not , , , , , , , , , , , , , consider themselves sick and thus did not adopt the value , , ,, ot a health continuum _ „ _, i . , ,r . , i Finally, The models failure, it was suggested, was i i i e soaologically , , ,

defaned as medical hostages, and as can be appreaated,

patients are required to ht the cntena of bemg dangerous, , ° , , '^'^ 1 . 1 1 L'/xxLiuKLAL hostages have a very limited capaaty for negohahon violent or have criminal propensihes (Mental Health Act r J o HMSO 1983) which is most assuredly a socially consfructed rahonale for compulsory detenhon IneffecHve nursing models In the previous work camed out it was suggested that Ashworth the Corresponds 1350nursmg Hospital, TamMason models Parkhoum ChargeNur^ used m Maghull Roam the 13 speaal M4Bmldmg Mersei/suk hospital AshwarthSouth LSIfailed lHW England Having ^^^^^ ^°'worked "^V models y^^rS withmused itthe WaS speaal Were a x i Ogenerally mhospitals a h c t h a t meffechve at t h ea dirucal n u r s m at g provi

Nursing models in a speaal hospital

framework for lmplementmg care or achievmg the objechve of altermg the condition of the patient or the environment in which she or he bves Yet relahvely bttle research has been camed out to identify whether there is empincal evidence to support or falsify such axioms Certamly the previous works ated would mdicate that the tradihonal models adopted were m reality implemented because it was pobtic to do so and not because of their suitabibty for the specific special hospital setting However, despite these attempts to 'fix' the problemahc of nursing models in a speaal hospital withm the contextual nature of the settmg, there are altemahve analyses which may indicate that their mefficacy may be a result of the educational approach to the models which ultimately affects how the models are perceived From the basis of these foregoing works, this study aims to provide a theoretical framework to conceptualize how the nursmg models were perceived and their current function withm nursmg practice

METHOD Semi-structured interviews of 40 pnmary nurses, who were actively using or attemptmg to use a nursmg model of care, were undertaken The interview schedule was a senes of open-ended statements/queshons relatmg to the nursmg models, following which the subjects were asked to comment Such statements/questions induded, for example 1

2 3

Patients in a spwaal hospital progress faster through the system when cared for withm a framework of a nursmg model Without a nursmg model for guidance nursing care is less systematic How IS the nursing model to be prachcally implemented?

As can be seen, these statements/questions are designed to be provocative rather than incisive, which evokes a discourse from the subjects in relation to their perceptions of models, forensic patients, speaal hospitals, culture, etc Contemporaneous notes were taken of the subjects' discourse, which were then typed for ease of codmg The notes were verbatim statements from the subjects m direct response from the mterview schedule and mduded, for example

their concepts really no relationship to what's going on out there [points to ward community] what does that mean? If it's supposed to apply structure — it doesn't well, not a structure that fits what's going on They're good for the students they like all that we keep the models there [points to notice board] so we can refer people just another fashion The theonsts come down here [to ward] and give us all that [models] They [tutors] very quickly forget once they've left the grass roots [clinical practice] well er that's a good one I suppose that er [pause] what you do is estabbsh the patient's problems as you would anyway er but withm theframeworkof the model It's a focus really it [model] keeps you up to date really I suppose If I'm honest I don't think they [models] are related to prachce here [speaal hospital] Indexical expressions Indexical expressions were ldenhfied which signified the subjects' focus of attention in relation to the nursing models and their effectiveness in mfluencmg pahent care An mdexical expression refers to properties or signs that are manifested from a person's account (speech) and which can be understood m relation to the socially organized occasions of their use Garfinkel (1967) comments [mdexical] expression whose sense cannot be deaded by an auditor without his necessanly knowing or assummg something about the biography and the purpose of the user of the expression, the arcumstances of the utterance, the previous course of the conversation, or the particular relationship of actual or potential interaction that exists between the expressor and the auditor This dearly locates the interviewer and the subject m a social/contextual situation in which there is an understandmg of the features of the organizahon The analysis of these accounts therefore, focuses upon the rational properties of these mdexical expressions as everyday accomplishments, the basis for this bemg to identify how the subjects use the rational properhes, unknown to them, as 'obvious' or 'common sense' As Carfmkel (1967) explams The recogntzedly rational properties of their common sense mquines — their recogmzedly consistent, or methodic, or uniform, or planful etc character — are somehow attainments of members' concerted achvihes

'Oh, 1 can't bebeve that, no way [long pause] I mean, [pause] how do you think we've been doing it [nursing] all these Thus, the analysis mvolves recognizing the pattems or years? Look I'll show you [reaches for model documentahon] it's all very nice, isn't it? Lovely bnes and neat boxes, like themes emerging from the subjects' accounts

1351

T Mason and M Chandley

RESULTS From the discourses analysed (80% of population) two major themes emerged First, there was reference to the models as concrete enhhes m thonselves, both m terms of the paper, lines, graphs and boxes that serve to give boundanes, and the phraseology of the particular model used This reification led to a rebance on the model itself which perpetuated a defmitive and stagnated percephon, reducmg the potentiality for progress through a dialectical process The second theme to emerge was the adherence to the model as the focal pomt and not the mdividuality of the pahent nor the speafic contextual nature of the settmg This created the bebef that there was an mability to move forward in either theory or pradice Clearly, m this study the subjects were able to establish error m the application of these models of care but were unable to provide a soluhon other than a retum to the equilibnum of adherence to the models as real enhhes

DISCUSSION Cybernetics Cybernetics is concemed with how systems orgaruze, regulate and reproduce themselves and its foundmg father was Norbert Wemer (1894-1964), a Umted States mathemahcian The etymological denvahon is from the Greek kubemetes, meanmg steersman This relahvely new science attempts to understand how processes of information exchange can be used by inanimate objects and organisms to provide self-regulahon and the mamtenance of equilibnum A central theme m cybemehcs mvolves negative feedback, m which a system engages m error detection and automahc correchon so that ultimately error is ebmmated Examples of this concept indude a room thermostat that controls the central heatmg system, sweatmg when hot, and shivenng when cold, these bemg what is called basic forms of learning or smgle-loop leammg Nursing models, m the speaal hospital studied, it is argued, were adopted at this fundamental cybemehc level, m that the models themselves were reified and were expected to provide self-regulahon of the patients' and staff's behaviours The models had attnbuted to them a cybemehc mtelligence of the double-loop, or learning to leam, vanety which dearly they do not possess This form of dependence on models excludes mnovahon and therefore cannot change or adapt outside the parameters of the smgle loop 1352

Major problem The major problem with cybemetic single-loop learning is that it IS always dependent on the predetermmed norm, standard or value that is set, and does not have the ability qualitahvely to react to mappropnateness For example, once the thermostat is set, the heat comes on or goes off accordmg to the range, but cannot take account of the state of the individuals withm the room The human brain, and some complex computer systems, have the capaaty to do just this, and can leam to leam, m double-loop fashion, produang change and innovation Unfortunately, nursing models used in this speaal hospital were adopted with their inherent value (Mason & Chandley 1990) and predetermmed standard which failed to take account of the specificity of the settmg and became locked into the single-loop system Such smgle-loop dependence on models as 'thmgs' m themselves which can solve the problematics of nursmg practice result m merely another type of stagnation What appears to be necessary, from the cybemetic theory of communication and learning, is the capacity to adopt a double-loop approach based on four key pnnaples First, that systems must have the capaaty to sense, monitor, and scan significant aspects of their environment Second, that they must be able to relate this informahon to the operating norms that guide system behaviour Third, that they must be able to detect significant deviations from these norms And fourth, that they must be able to initiate corrective achon when discrepanaes are detected (Morgan 1986) Hyperreality From the cybemetic imagmary, Jean Baudnllard, the contemporary French philosopher, developed the nohon of hyperreality, in which the simulations m soaety become more real than the real It must be emphasized that within this concept, for Baudnllard, 'the hyperreal is not the unreal but the more than real, the realler than real' (Kellner 1989) The representahon, the copy, the replica takes the place of that which it sigrufies and thus becomes itself the central focus Just as Foucault (1977) highlighted the existence of pnsons as a camouflage to hide the fact that it is soaety itself, m its entirety, that is carceral, so Baudnllard (1983) suggests Disneyland is there to conceal the fact that it is the 'real' country, all of 'real' Amenca, which is Disneyland it is meant to be an infantile world, m order to make us bebeve that the adults are elsewhere, m the 'real' world and to conceal the fact that real childishness is everywhere

Nurstng models m a speaal hospital

From this study the nursing models appear to have taken on this hyperreabty, in that they are focused upon themselves rather than that which they are supposed to represent The models become the reality rather than merely reflecting reality 'In a hyperreal world, the model comes first, and its constituhve role is invisible, because all one sees are lnstanhations of models' (Kelber 1989) Thus the conshtutive role of nursmg models of care, that is their essential reason for being, to affect patient care, remains hidden, whilst the focus of attention is on the lnstantiahon of the model itself, this moment in time, the image, the reflechon, and what it now means as distinct from its ongmal formation

This new awareness of the necessity for selection of appropnate nursing models seems ever more important given the inevitable and understandable conflict expenenced by nursing staff (Baldwm 1983) Baldwm's (1983) 'necessity' is, in the authors' opinion, quite correct However, this present study mdicates that another form of stagnation results from a hyperreal focus on the models themselves This bmits the boundanes to expansion and development and is as true for nursmg models as it is for the 'nursing process', 'pnmary nursing', 'quality assurance', quality circles, 'negotiated care', 'rehabilitation', 'research' and 'cnhasm' itself

Science of semiotics

According to Baudnllard (1983), in the hyperreal world the realities of signs, signifier, signified and simulacra are absorbed and create an end m itself, an end m which there can be no creativity, no innovahon, no lateral thinkmg, no pushing of the boundanes of thought These terms, signs, signified, signifier and simulacra, belong to the science of semiohcs which is a branch of lmgiushcs that is traditionally divided mto three parts syntadics, the study of grammar, semanhcs, the study of meanmg, and pragmatics, the study of the actual purposes and effects of mearungful utterances From the semiotic position sense is made of our soaal world by signs, which are the extemal indicator of the signifier, le the meaning structure of the person from whom the sign ongmates, who has a referent, the signified which can only be indicated via a sign An example is called for A signifier, a person who wishes to indicate where one should rebeve one's bladder, establishes from his or her own meaning structure a sign, the trousered gentleman and the sbrted lady, to refer to a domain that permits one to relieve oneself, the signified Between these elements, signifier, sign and signified, there IS a relationship which is imagery, pretence and deceptive, which requires lmagmation to interpret, this being the simulacra The removal of metaphor and metonym, that is the relationship between a thmg meant and a substituted sign, removes imagination This BaudnUardian philosophy would suggest one reason why the nursmg models fail to progress m the speaal hospital studied They have been absorbed into hyperreality Baldwm (1983) highbghted the apparent 'growing and jushfiable fiiistrahon of nursmg staff m speaal hospitals', and went on to argue for 'the need for considerahon of model selection and model utility' Tbs was perhaps an early mdicahon that the speaal hospitals were entermg (or had entered) a phase of hyperreabty and nursmg models needed to be carefiilly selected or developed

Beyond In order for development m speaal hospital nursmg practice to emerge there is a need for reflexivity and dialectics Reflexivity concems the philosophical notion that, as one's thoughts produce action, speech, the doing unto others, there is an lntelbgible presupposihon that it will be mtelbgible for the other An action, or a word, is a mere mdex into a whole meanmg structure, for oneself, and for the other Although the other's meaning structure can only be imagined and interpreted via their use of actions, languages, etc, this forms the basis of semiotics within cultural boundanes The important point in reflexivity is that the achon, language, etc, of oneself m the doing is 'bent back' mto one's thought processes and contnbutes to a growing 'stock of knowledge' Thus, the scene is set for potenhal innovahon, change and development (Lawson 1986) Dialectics, a Greek word originally associated with the Socratic method of argument through dialogue and conversation, requires constant questionmg of basic assumptions Through the conflict of this questioning process thought emerges leadmg to solutions to the contradichons This emergent thought develops and provides the basis for innovation Clearly within this Hegelian notion, thought is reabty, and the laws that thought must follow are also the laws that govem reabty Therefore, if no questionmg is undertaken, then no change will occur Hopefully, it will be dear by now that the earber sechons of this paper, on cybemehcs and hyp>en"etility, are a result of this reflexivity and dialechcal process It therefore could be argued, as they are a result of these processes, that they could be misplaced bemg pnor to this sechon on 'Beyond' This would be a fair comment However, as the process is one of an evolvmg spiral, and new thought should be contmually sought, it seemed more appropnate to hint at somewhere beyond for the speaal hospitals 1353

T Mason and M Chandley

CONCLUSIONS

References

As the speaal hospitals enter a 'new phase' of development there is an ever-increasmg need to question the underlying assumphons on which the practice is based However, the important point is that whilst managers may manage, and teachers may teach, it is the dmiaans on the wards that are cenfral to the future Only by the 'doers' reflechng on their prachce, questionmg and developing new thought, and tummg it back onto the practice agam, will appropnate change occur If it IS left to the theonsts and the armchair philosophers who have no knowledge of the practice, they will get it wrong

AshbyWR (1960) An Inhoduchon to Cybemehcs Chapman Hall, London Baldwin S (1983) Nursing models m special hospital settings Joumal of Advanced Nurstng 8, 473—476 Baudnllard J (1983) Simulahons Semiotext (e). New York. Foucault M (1977) Disaplme and Puntsh Peregnne, London Garfinkel H (1967) SWies m Ethnomethodology Pobty Press, Cambndge HMSO (1983) Mental Health Act HMSO, London Kellner D (1989) Jean Baudnllard From Marxism, Poshnodermsm and Beyond Polity Press, Cambndge Lawson H (1986) Reflextvity The Poshnodem Predicament Unwm Hyman, London Mason T & Patterson R (1990) A cntical review on the use of Rogers' model within a special hospital a smgle case study Joumal of Advanced Nursing 15(2), 130-141 Mason T & Chandley M (1990) Nursing models in a speaal hospital a cnhcal analysis of efificacity Joumal of Advanced Nursing 15(6), 667-673 Morgan G (1986) Images of Organisahon Sage, London

Disclaimer The opinions expressed m this paper are those of the authors and do not necessanly refled those of the special hospitals

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Nursing models in a special hospital: cybernetics, hyperreality and beyond.

Two emerging themes that resulted from research carried out in a special hospital on the use of nursing models are identified. The first theme to emer...
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