Andrzej Brodziak (1, 2), Ewa Zarzyka (2), Ewa Ziołko(2)

1. The tool useful for the therapist and the environmental nurses in assessing health status and its determinants in patients visited in their homes. Andrzej Brodziak (1, 2), Ewa Zarzyka (2), Ewa Ziołko(2) Institute of Occupational Medicine and Environmental Health in Sosnowiec, Poland 2. Institute of Nursing - State Vocational High School in Nysa, Poland Address for correspondence.: Prof. dr hab. n. med. Andrzej Brodziak, Institute of Occupational Medicine and Environmental Health, Sosnowiec, ul. Kościelna 13, Poland tel. (48 32) 266 08 85, e-mail.: andrzejbrodziak@plwp.

2. Introduction It seems there are two different models of solving the health problems of patients. Usually the need for assistance of a doctor is made during the patient's first visit to a GP or in another out - patient department. Sometimes these are the similar circumstances in the emergency room of a hospital.

3. In this classical model of handling medical problem the first conversation between the doctor and the patient is realized at the doctor's desk in his office. During the interview the patient described his complaints, symptoms, and gives other data that are typical for so called medical interview. Usually the doctor performed later the physical examination of a patient.

4. Note that in this classical model all data come from only one "channel of information" - it means through the patient's verbal report. Only sometimes the patient is accompanied by family members and a doctor takes a portion of the data from them.

5. A different model of the data acquisition is to go where the patient resides. Home visits are sometimes carried out by the so-called GP - General Practitioner ( home doctors). In such circumstances the doctor may collect information about the patient, not only from him. It can then look around and see the environmental determinants of health. It is also easier to contact with the family members.

6. What's more, your doctor may notice signs of a specific features of relationships, which exists between the patient and his partner, or between the patient and his parents. He may then ask questions relevant to the assessment of the relationship. It can also assess the living conditions of the patient and asses so-called environmental harm.

7. The second model described here, speaking metaphorically is similar to the investigative steps, although in this case they are made by friendly motives - the willingness to help the sick. This model can be illustrated - perhaps quite accidentally - by the scenario of a known show about Dr House.

8. Recently medical journals emphasize the favorable characteristics of this "in patient's home visit" model of acquisition of data about the health problem. One of these journal writes about "a new occupation", which is to be called "Environmental therapist" and about a new form of action through so called "Environmental Treatment Teams" (1).

9. The author of one of this articles about the "Environmental Treatment Team" writes.: ".. I visit as a specialist the patient in his home and spend there at least one hour, I discuss with him, I see his home - an environment in which he lives, I see and talk to his family, loved ones ... his home can be visited by several specialists ... After returning to the office of "Environmental Treatment Team" – I discuss the gathered data with colleagues. We work as a team. We exchange ideas, decide whether, how often and by whom the patient is to be visited. What has to happen as a result of our visits... "

10. Although the role of the "Environmental Therapist" and "Environmental Treatment Teams" is promoted recently vividly it should be emphasized that the organization of the health services in Poland provided the positions of so called "Environmental nurses", acting on behalf of the general practitioners at homes of patients. The recent initiatives extends a „new profession" of "environmental Therapist” to the doctors - which is obviously a valuable initiative.

11. Having the possibility to talk with many environmental nurses in seminars conducted during so-called " bridging studies for nurses supplementing their knowledge", we saw the need and opportunity to develop an additional tool that would be helpful for the environmental therapist and the environmental nurse to assess health status and situation of visited patients.

12. Namely, we formulated the procedure and we developed the tool facilitating the recording of data gathered during the visit at home of a patient and illustrating the recorded state of health with different circumstances of his being and health. In formulating this tool we used the experience that we presented in our previous work (3).

13. General theoretical assumptions of the method. The most important function of the procedure described here, performed by a environmental nurse or therapist necessary to achieve a single-application of this method is to obtain data about the patient and record them in eight "scales" (domains) which describes not only health but also experienced existential and environmental burden, living and social harmful factors and defining mental resistance

14. The methodology of formulating these "scales" is consistent with the rules of construction of sociological tools. As is well known - sociological structured interview, for a given area is created according to specific needs, arising from the consideration of the problem known from the literature and personal experience.

15. We propose that the predicted domains include some of the areas described in our earlier work concerning the evaluation of health status (3,4,5) with addition of "scales" determining environmental conditions. The predicted pattern of gathered data are presented in the appendix, which serves also as the protocol of the planed structuralized interview.

16. An important part of the tool is a method of the graphical illustration of results of the evaluation of a patient's situation. As a tool of illustration we propose to implement the so-called „multi - dimensional graphs (called profiles in the shape of rosettes)” applied - as it seems for the first time in so-called.: "The World Justice Project - Rule of law index" (6).

19. Determination of the areas most relevant to characterize the health and environmental conditions. We proposed earlier (the following definition of health status 4) .: { The current health status is determined by [# 1] state of organs, which take into account unfavorable changes the body structure [# 2] important determinants of psychological well-being, [# 3] not externalized, but potentially yet important genetics determinants of the health [# 4] the functional efficiency of the body and the size of the living space }

20. Taking this definition as a basis for the formulation of the content of the planned structured interview, which would be implemented by environmental nurse - we predicted the following areas(domains).: 1. Review of the physical state of the body, realized therapy, nutrition and genetic conditions 2. Adverse events in childhood 3. Loneliness - emotional engagement - partner 4. Relationship with other people, communication skills, general mental condition 5. Professional and social challenges 6. Living conditions 7. Environmental harm 8. The functional capacity of the body.

21. Content of the enumerated domains is included in the annex, so that it can also serve as a protocol of the structurized (standardized) interview helpful to nurseand/or environmental therapist. If any of you would like to receive the contents of this protocol - I will transfer it as a copy of a file, under Word, recording it to your pen drive.

22. The method of the graphic illustration of the health status and environmental conditions of the visited patients. The procedure of the proposed method provides for the gathering of data according to the content of the structuralized interview organized in 8 domains. It is expected that the result obtained for each of such "dimensions" will be pushed on one of eight axes of multidimensional profile - named here also as "rosette". This way of illustration, as we mentioned is borrowed from the "The World Justice Project - Rule of law index" (6). This action leads to the formation of a map drawn on the chart presented on the figure no 1.

25. It is needed to remark the following characteristics of such multi-dimensional profiles. • The different kind of scales can be included into the multi-dimensional profile. • It can e a so called nominal scales (eg such as the Richter scale or Boforta) or cumulativescales which defines the number of points awarded for a set of questions not related bythe increasing gradation. They can be also so called "repertory grids", which are resulting from the personal construct theory of George Kelly (7, 8) • 2. The scales should be normalized in such a way that values in each of them • is from the interval <1, 10> • 3. The scales should know oriented in such a way that he was favorable result • are ranked toexternal directions of the profile and negative values are located • near the center of the graph. • 4. In such circumstances, the results for people who show little adverse events • determine a large area encircled by bounding line. This allows to become • quickly acquainted withsummary conclusions. • 5. After reaching the skill in the interpretation of such plots, it is possible at • a glance to estimate the specific situation of the tested person.

26. The results of preliminary application of the method. This paper aims to present mainly the theoretical basis of a new method, so we present only preliminary results of its application. This procedure was used to retrieve data from 16 patients, who were visited in their homes by a visiting nurse (by one of us - 2) and from 6 patients visited in their homes by a doctor (one of us -1). Due to the limited time of my lecture I will present data obtained from only some patients. These data are presented in the form of a (1) short medical report and (2) the obtained answers, numbered according to the protocol set out in Appendix and (3) by presenting the graphs of the multidimensional profiles.:

27. A. Patient F.R. Medical interview - in short.: Male, age 19, a student of high school. Complains of diffuse abdominal pain, which occur for several months, intermittently, although only during the day, not depending on other tangible factors. The patient lost weight, about 3 kg. Data obtained during the structurized interview. For nominal and cumulative scales [ ] the numbers of items are given if the answer was "yes". For the repertory grid {} after the no of item the obtained value is given, which is the number from the range < -10, 0, +10 > [ 1.18, 1.21 ] [ 2.2, 2.9, ] [ 3.8 ] { 4.1+, 4.2+, 4.3 -0, 4.4+, 4.5 -0, 4.6 -0, 4.7+, 4.8+, 4.9+, 4.10+ } = + 7, ie 85 % of scale { 5.1+, 5.2+, 5.3+, 5.4+, 5.5+, 5.6+, 5.7+, 5.8+, 5.9+, 5.10+ } = +10, ie 100 % of scale { 6.1-0, 6.2+, 6.3+, 6.4+, 6.5-0, 6.6+, 6.7+ , 6.8-0, 6.9+ ,6.10-0 } = +6, ie 80 % of scale { 7.1+, 7.2+, 7.3+, 7.4+, 7.4+, 7.5+, 7.6+, 7.7+, 7.8+, 7.9+, 7.10+ }= +10, ie 100% of sc. { 8.1+, 8.2+, 8.3+, 8.4+, 8.5-0, 8.6 -0, 8.7+, 8.8+, 8.9+, 8.10+ } = +8, ie 90% of scale

29. B. Patient R.K. Medical data - in short.: Male, age 45, does not work, means of living given by the family for several years. A significant alcohol abuse. Patient's family has asked for an appointment of the general practitioner because of seizures. [1.1, 1.2 (take periodic drug treatment), 1.5, 1.6 (quite often seizures when a trial of withdrawal of alcohol), 1.7 (from a few years alcohol dependence), 1.13. (father died at age 50 years) 1.15 (grandfather died of a heart attack at age 52 years), 1.18,1.19 (do not eat well because of frequent binge drinking), 1.20 alcoholism from about 7 years.] [2.1 (death of father), 2.6 (his father was also an alcoholic), 2.10 (overprotective mother) [3.3 (breakdown od sexual relations with a partner)] { 4.1-1, 4.2-1, 4.3 -0, 4.4-0, 4.5 -0, 4.6 -0, 4.7-1, 4.8-1, 4.9-1, 4.10+-1}= + 6, ie 20% of s. { 5.1-1, 5.2-0, 5.3-0, 5.4-1, 5.5-1, 5.6-1, 5.7-1, 5.8-1, 5.9-1, 5.10-1 } = +8, ie 10 % of s. { 6.1-0, 6.2-0, 6.3+, 6.4+, 6.5+, 6.6+, 6.7+ , 6.8-0, 6.9+ ,6.10-0 } = +6, ie 30 % of scale { 7.1+, 7.2+, 7.-1, 7.4+, 7.4+, 7.5+, 7.6+, 7.7+, 7.8+, 7.9+, 7.10+ } = + 9, ie 95 % of s. { 8.1-1, 8.2-1, 8.3-1, 8.4-1, 8.5-1, 8.6 -0, 8.7+, 8.8-1, 8.9-1, 8.10-1 } = - 9, ie 5 % of scale

31. It should be noted that the presented method facilitates the comparison of data obtained from several family members. It facilitates also the reference of patient's multi-dimensional profile to own profile prepared for the therapist or nurse. We propose to name it as self- reference procedure. These comparison procedures are realized by drowing of several profiles on one graph. Comparisons of results obtained from several family members e.g. the patient and his mother or referring them to a profile of the therapist helps to provide advices and guidance.

35. Data for H.K - the mother of the patient R.K. The mother of the patient R.K. is suffering by reason of several syndroms (obesity, rheumatic symptoms). She worry about the state of his son. Her general psychological condition is not well. [ 1.1., 1.2, 1.5, 1.12 1.13, 1.14, 1.15, 1.19 ] [ 2.1 ] [ 3.4.] {4.1-0, 4.2+, 4.3 -0, 4.4-1, 4.5-0, 4.6 -1, 4.7-0, 4.8-0, 4.9-0, 4.10+ } = 0, ie 50 % of scale { 5.1-0, 5.2-0, 5.3-0, 5.4-0, 5.5-0, 5.6-0, 5.7-0, 5.8+, 5.9-0, 5.10-0 } = +1, ie 55 % of scale { 6.1+, 6.2-0, 6.3+, 6.4+, 6.5+, 6.6+, 6.7+ , 6.8+, 6.9+, 6.10+ } = +9, ie 95 % of scale { 7.1+, 7.2+, 7.3+, 7.4+, 7.5+, 7.6+, 7.7+, 7.8+, 7.9+, 7.10+ } = + 10, ie 100% of scale { 8.1-0, 8.2-0, 8.3+, 8.4-0, 8.5-1, 8.6+, 8.7+, 8.8-0, 8.9-0, 8.10-1 } = +1, ie 55 % of scale 8

37. Preparation of multi-dimensional profiles and the imposition on the graph of the patient another graphs formulated for people who are potentially able to affect the patient (e.g. patient's mother, patient’s partner, the therapist) facilitates the formulation of advices. Tips are to take into account the real psychological possibility of flatmates or family members resulting from their mental condition. What's more - within the formulated therapeutic tool (the computerized file) the data can be included referring the nurse (therapist) to various forms of so-called. indirect psychotherapy (books, movies).

38. Conclusions • Implementation of the proposed method, as it seems, incline people involvedin the treatment of patients to take into account not only his physical health butalso determinants of mental health status, living and ongoing harm environment. • 2. Filled protocol of structured interview and the multi-dimensional • profile facilitate the transfer of gathered information to other • person involved in the treatment and the discussion of found • circumstances. • 3. Filled protocol of structured interview and the multi-dimensional • profile helps to plan activities that should be next steps of • treatment, and also to determineactions which would useful • as social intervention.

39. 4. The presented method facilitates the comparison of data obtained • from several family members. • Themethodfacilitates the reference of patient's multi-dimensional • profile to own profile prepared for the therapist or nurse • ( a self- reference procedure ). • 6. The imposition on the graph of the patient on another graphs formulated for people who are potentially able to affect the patient facilitates the formulation of advices. • The further attempts of the practical use of the proposed methods • will provideguidance for various modifications of standardized interview. • 8. It seems that the long-term use of this method will enable to • determine an optimal set of elements of the planned • standarizedinterview.

40. Some words about The World Justice Project.: „ The World Justice Project (WJP) is a multinationaland multidisciplinary effort to strengthen the ruleof law throughout the world. It is based on twocomplementary premises: first, the rule of law isthe foundation for communities of opportunity andequity; and second, multidisciplinary collaborationis the most effective way to advance the rule of law.

41. ["... The WJP Rule of Law Index presents a comprehensive set of indicators on the rule of law from the perspective of the ordinary person. Itexamines practical situations in which a rule of lawdeficit may affect the daily lives of ordinary people. For instance, the Index evaluates whether citizens can access public services without the need to bribe a government officer; whether a basic dispute among neighbors or companies can be peacefully and cost-effectively resolved by an independent adjudicator; and whether people can conduct their daily activities without fear of crime or police abuse...]

42. The Index provides new data on the following nine dimensions of the rule of law: » Limited government powers » Absence of corruption » Order and security » Fundamental rights » Open government » Effective regulatory enforcement » Access to civil justice » Effective criminal justice » Informal justice

43. These nine factors are further disaggregated into 52sub-factors. The scores of these sub-factors are builtfrom over 400 variables drawn from assessments ofthe general public (1,000 respondents per country)and local legal experts. The outcome of this exerciseis one of the world’s most comprehensive data setsmeasuring the extent to which countries adhere tothe rule of law—not in theory but in practice.

44. Factor 1: Limited Government Powers Factor 2: Absence of Corruption Factor 3: Order and Security Factor 4: Fundamental Rights 4.1 Equal treatment and absence of discrimination are effectively guaranted 4.2 The right to life and security of the person is effectively guaranted (is eff.guar) 4.3. Due process of law and the rights of the accused are effectively guaranted 4.4 Freedom of opinion and expression (is eff. guar) 4.5 Freedom of belif and religion is effectively quaranted 4.6 The right to privacy is effectively guaranted 4.7 Freedom of assembly and assoctiation (is eff. guar) 4.8 Fundamental labor rights are effectively guaranded Factor 5: Open Government Factor 6: Effective Regulatory Enforcement Factor 7: Access to Civil Justice Factor 8: Effective Criminal Justice Factor 9: Informal Justice