doi: 10.1111/nup.12088
Original article
Cyborgs, biotechnologies, and informatics in health care – new paradigms in nursing sciences Ana Paula Teixeira de Almeida Vieira Monteiro RN MSc PhD Adjunct Professor, Coimbra Nursing School; Researcher; Health Sciences Research Unit-Nursing, Coimbra, Portugal
Abstract
Nursing Sciences are at a moment of paradigmatic transition. The aim of this paper is to reflect on the new epistemological paradigms of nursing science from a critical approach. In this paper, we identified and analysed some new research lines and trends which anticipate the reorganization of nursing sciences and the paradigms emerging from nursing care: biotechnology-centred knowledge; the interface between nursing knowledge and new information technologies; body care centred knowledge; the human body as a cyborg body; and the rediscovery of an aesthetic knowledge in nursing care. Keywords: epistemology, biotechnology, computers, cyborgs.
Background Nursing is in a moment of paradigmatic transition, both in the epistemological and social dimensions. In this transition process, it is possible to glimpse epistemological alternatives and a new paradigm emerging from scientific knowledge, based on a broader rationality, the overcoming of the nature/society dichotomy, the complexity of the subject/object relationship, the approximation of pure sciences to humanistic studies, and a new connexion between science and ethics (Santos, 2010). Radical social transformation also challenges the reconstruction Note: This article is based on an article first published in Portuguese in the journal Pensar Enfermagem. Correspondence: Profª Doutora Ana Paula Teixeira de Almeida Vieira Monteiro, PhD, Adjun, Coimbra Nursing School, Avenida Bissaya Barreto – Apartado 7001, Coimbra 3046-851, Portugal. Tel.: 00351239 802 850/239 487 200; fax: 00351239 442 648/239 483 378; e-mail: [email protected]
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of nursing sciences in several domains: global population ageing; the epidemiological explosion of degenerative and mental illnesses; the aggressive medicalization of everyday life; and the crisis in the welfare state. The contemporary affirmation of Nursing Sciences arises from the intensive everyday life medicalization – the growing intervention of medicine in the most private domains of human experience (Crawford, 1980) and the biotechnological sophistication, which characterized the evolution of medicine throughout the 20th century. Over several decades, scholars have attempted to encompass the trinity of physical, psychological and social aspects of care in theories and models of nursing, which were intended to guide practice and provide a platform for training curricula and research, thus supporting the development of professional knowledge.
(McCrae, 2012)
The quest that began in the last quarter of the 20th century has been fostered by several factors, including
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nursing education’s move from the hospital to the academy, changes within nursing itself, and the feminist movement. In this process, nursing sciences has asserted itself scientifically and socially by its attachment to the mechanicist and organicist biomedical model, while paradoxically, the theoretical– conceptual nursing models proclaimed the holistic dimension of person-centred care. Adopting professional practice towards technical rationality, associated with the influence of taylorization, transformed nursing care into an essentially technical act, arising from the medical act (Amendoeira, 2004). The biomedical understanding of human illness and suffering is reflected in the material practices of the medical profession, which for over a period of two centuries has been able to establish its dominance within the evolving organizational system of health care (Crinson, 2007). The epistemological building of an autonomous knowledge in nursing was translated into a positivist and materialistic discourse, associated with the notion of clinical efficacy or the conceptual idea of evidencebased knowledge, and it was consolidated in the hospital settings of invasive technologies. In fact, the greater the complexity of health technologies and settings where nurses develop their practice, the higher is their professional status and the acknowledgement of their scientific potential. From ‘physicians’ assistants’ to ‘almost physicians’ or even ‘physicians’ substitutes’, nurses are performing roles that not so long ago were strictly reserved for the medical profession. However, the nursing interventions’ paradigms are only apparently changing while keeping the original hierarchical dependence of physicians’ power knowledge (Carapinheiro, 1993). One of the central issues in the literature is to know whether nursing science ought to be based on a multiparadigmatic epistemic structure, or on the contrary, the knowledge produced should be synthesized around a specific model, which would guide research and praxis. The current theoretical models of nursing sciences and the recent empirical research in this field refer to a multiparadigmatic epistemic substrate which includes both qualitative and quantitative approaches, and the integration of the complexity, simultaneity, and totality paradigms in the nursing
discipline (Parse, 1987; Kérouac et al., 1996; Cody, 2005; Struby, 2008). Multiculturalism, multiprofessionality, humanism, identity, autonomy, and excellence of care are today at the centre of the debate around the academic and professional components of the nursing discipline (Abreu, 2001; Monteiro, 2014). Monti & Tingen (1999) believe that multiple nursing paradigms allow for unconventional and new thinking, stimulating concepts, and a diversity of views. The current nursing paradigms undertaken by the scientific community as theoretical references for the development of the discipline set the discussion around the possibilities and scenarios of development that emerge where the limits of ‘normal science’ managed to silence other possible paradigms. It is Kuhn’s premise that science does not build upon itself in a linear progression. In normal science, the paradigm is already preformed, providing a foundation of theories, ontological assumptions, and procedures with which to work. In this sense, paradigms streamline the process of science, so long as normal science does not encounter major stumbling blocks that contradict its foundations (Kuhn, 1970). The new emerging paradigms, asserting themselves on other frameworks which, until now, could not be designed in nursing as a reflection in the strict limits of ‘normal science’, create a set of opportunities and challenges to the reconstruction of beliefs within the scientific community with regard to the conceptualization of reality in nursing (Irigibel-Uriz, 2010). Postnormal science paradigm (Funtowicz & Ravetz, 1993) opens the possibility for ‘narratives’ as a means of addressing complexity. Also in nursing sciences, narratives provide important additions to factual claims ‘because they are not about objective reality, but are statements of what is significant’ (Allen & Giampietro, 2006, p. 595). Nursing is hard to define as an autonomous science. As a result, it has a complex, fragmented identity. In this epistemological transition, there are some research lines and trends that anticipate the reorganization of Nursing Sciences, and the emerging of new paradigms in nursing care. This paper will be structured in the following way. Firstly, we will examine the theoretical debates within
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Nursing Sciences and the problems about how to integrate biotechnologies, robotics, and information technology (IT) into a coherent understanding of nursing care. Secondly, we will examine how the new paradigms emerging in Nursing Sciences (a biotechnologycentred knowledge; a person care-centred knowledge integrating the cyborg ontology, and a rediscovery of an aesthetic knowledge in Nursing) can contribute to a multiparadigmatic model, bringing together classic with postmodern paradigms of care.
A biotechnology-centred knowledge Nursing Sciences still adhere to a humanistic vision of technology, by classifying technology as non-human or non-natural, integrated into a conceptual vision where a cleavage between human/non-human and nature/technology occurs (Barnard & Sandelowski, 2001). Some empirical studies and theoretical conceptualizations describe nurses as the mediators or the bridge over the gap between aggressive technology and humanized therapeutic space. Therefore, nurses are responsible for maintaining health care humanity in technological environments (Halm & Alpen, 1993). However, both innovation and technological sophistication in health sciences, especially in hospital settings, have been growing so exponentially that the scientific discourse on the theme (humanized nursing care versus technologies) has undergone a subtle change. It is now considered that technological skills are absolutely essential for the provision of nursing care. Humanization of care necessarily implies the implementation of more aggressive technological environments (Lapum et al., 2012). Nurses are no longer the ‘mediators between two worlds’ but a structural element of biotechnologies applied to health care or disease processes. Technology, in particular those considered as ‘hard technologies’, is regarded as essential for the efficient provision of care and health assistance (Vargas, 2002). Nursing scientific discourse and research on the frontiers of care versus technology usually focus on intensive care units or emergency rooms – settings where high technological sophistication and use of intensive technology to carry out diagnoses and therapeutics are central. The nature of the work
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developed in these units focuses on specialization, requiring highly elaborate and accurate work instruments and procedures, where a central role is played by technological equipment. This leads to strictly technical and mechanistic activities, in which the nurse focuses on the area of technology related to the patient and invasive activities, putting deep relationships between nurse and patient/family in the background (Saiote, 2013). There are already some experiences involving biological connections and computer systems, digital interfaces between living tissues. Some standardized technological artefacts of homogenization and control can be used by nurses in their daily clinical practice. The actual trend is the ‘robotization’ of tasks that are classically considered as nursing responsibilities or tasks that are usually mediated by nurses (e.g. assessing, measuring, and monitoring vital signs). Robots are currently being developed to assist the elderly and people with motor disabilities in some activities of daily living.In fact,the expression nurse robot is becoming a clinical reality: Experimental studies are still being carried out on prototypes, and they are having some impact in Japan. In some units, nurses are already being replaced by robots. New technology in Japan has resulted in a kind of robot intelligence known as ‘kansei’ (Ken-Zi), which literally means ‘emotion or feeling’. Kansei robots monitor human expressions, gestures, and body language and listen to people. They also sense human emotion through sensors that monitor pulse rate and perspiration (Huston, 2014). We are beginning to understand the apprehension concerning the way in which life-like robots are being introduced for the care of older adults. In the process of our interactions with these artefacts we could progressively experience transformations in our basic understandings of ourselves – transformations deep enough to merit our serious attention while we still are capable of distinguishing the alternatives’. (Metzler & Barnes, 2014, p. 13)
Interface between nursing knowledge and new ITs The ever-evolving, technology-intensive nature of the 21st century health care has caused acceleration in the
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division of labour, whereby work practices are becoming highly specialized, and the communication of knowledge is in a constant state of flux (Ludvigsen et al., 2011). This poses a challenge for education and learning in nursing. New information and communication technologies are drastically reconfiguring the way scientific knowledge in nursing is constructed and disseminated.They are also making profound changes in the nursing planning, operationalization, and sense of caring in clinical settings. Nowadays, in developed countries, nursing education is mostly based on the implementation of teaching–learning models where IT platforms, e-learning, and virtual information are in the front line. The dissemination of learning processes through the use of clinical practice laboratories in virtually simulated environments or with IT application models represents a new approach of pedagogical methodologies in nursing (Luzio, 2006). In these learning processes, human mediation and faceto-face contact tend to become scarcer, fragmented, and almost non-existent in some areas of nursing education. Also in clinical practice, IT systems that support nursing practice are revolutionizing the way in which nursing care is structured, operationalized, implemented, and assessed (Dreyfus, 2001). The implementation of IT systems in nursing (Support System for Nursing Practice) required a profound redefinition of the activities developed in the course of the provision of nursing care to the client, implying new forms of interaction, sociability, and reorganization of control mechanisms. The main features provided by IT systems allow nurses to register interventions resulting from medical prescriptions, data resulting from nursing assessment, and nursing interventions or care plans. However, computer language itself is a challenge to autonomous reflexivity in clinical practices and counteracts holistic approaches to care – the essence of nursing (Collière, 1996). Even though it was built from the biomedical model, the affirmation of nursing as a ‘profession’ has always used other languages, which are also procedures in context, rooted in this central concept of care. Is the computer language applied to health systems and nursing classifications reconfiguring the essence of care? Will it be a kind of care robotization, in which
the humanization has to be put aside permanently in favour of effectiveness rankings and invasive intensive technology? How is this expressed in language? Some authors have questioned whether standardized nursing diagnoses may be a restrictive, objectifying, and alienating option of the biomedical model. Does a methodology that involves the reductive fragmentation of the person to problem-type computerized ‘diagnosis’ not imply overlooking the fact that reality is holistic, and analysing problems outside the context that provides them with meaning? (Moya, 2006). The attempt to computerize nursing care has resulted in the International Classification for Nursing Practice (ICNP®), drawn up by the International Council of Nurses, with the purpose of standardizing scientific terminologies used in nursing, by gathering the diagnoses, interventions, and outcomes of nursing practice. The aim was to establish a common language, allegedly universal, to describe and document nursing practices, providing nurses with a vocabulary which could be used to include nursing data in IT systems. The ICNP has been presented as an instrument for facilitating communication among a professional group, or among the actors of the health system, possibly improving the quality and effectiveness of care. It is also assumed in several national and international documents that the information resulting from nursing data recorded using the ICNP can be used to plan and manage nursing care, in financial forecasts, to analyse patient outcomes, and to develop health policies (International Council of Nurses-ICN, 2005; Ordem dos Enfermeiros (OE), 2009). Due to its nature, the characteristics of the standard classification of care systems and nursing interventions with the aim of transforming them into computerized language cannot include too many details. The ultimate goal is to build databases that allow the digital archive of information that is very close to the statistical description of simplified task listings. This means that the notion of nursing care is drawing closer to the statistical concept. There is, therefore, an insolvable paradox in the process of computerization of nursing care parameters and nursing prescriptions. It was not the com-
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puter language and informatics programming that were adapted to nursing care models and their theoretical background. It was precisely the opposite. Computer language, which is, by definition, simplistic, fragmentary, descriptive, task-based, and limited to the performance of biomedical techniques, has overlapped reflexivity, the holistic dimensions, and complexity of the concept of nursing care. There is growing evidence that computer ratings cannot translate the specific practices and knowledge of nursing professionals, and they do not automatically imply an effective improvement of care (Pozo, 2013). Even more radical are the cleavage and the transcultural inadequacy if we think about language as being based on experiential concepts of intersubjectivity. The ICNP nursing diagnoses are no longer based on the model of basic needs or levels of dependence as in the previous rating models; instead, they have adopted a terminology that arises from the biomedical model which is limited to a group of clinical symptoms. The medical and the nursing diagnoses become almost overlapped in terms of language, meaning, and lack of differentiation. First of all, the new ITs applied to health care are also systems to access, search, process, use, and disseminate information. They work as support mechanisms for the implementation of new management models and approaches in an essentially economicbased and business model (Cunha-Filho, 2003). In the structural organization of health services, informatics processes are targeted to the standardization and control of nursing care in a perspective of information archive in databases, having the tayloristic division of work and the notion of task work as conceptual models. However, the computer revolution goes beyond technological equipment management (correlated with intensive biotechnologies) or clinical information management systems. We are still at an early stage. The aggressive digitalization of everyday life (Monteiro, 2013) in health associated with the exponential technological innovation and artificial intelligence (computers that learn by themselves) is a growing reality. Another important dimension has to do with clinical prescription decisions. The nursing judgement, diagnostic formulation, and prescription
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of interventions will be carried out by computing systems with no human mediation, as is the case with other decision-making scenarios in hypercomplexity contexts (Harper et al., 2008).
A body care-centred knowledge: the human body as a cyborg body Nursing sciences have focused their epistemological construction in person centred (body to body, skin to skin, and face to face) care where the human body is seen as a central artefact of the very notion of humanitude. However, the radical innovations of biotechnologies and new information systems in health imply the reinvention of body-centred care. The concept of cyborg is particularly important when discussing the emergence of new forms of scientific knowledge in nursing.A cyborg is a cybernetic organism, a hybrid of machine, and a biological organism, which incorporates the human and the non-human, the ‘natural’ and the ‘artificial’, but at the same time, it assumes a new entity which is irreducible to any dualism or hierarchy (Haraway, 1991). Nowadays, the human body moves within a new frontier: the space for the dematerialization into a prosthetic body, a space for postbiological and posthuman aesthetic, a space for cloning, replication, robotics, human action simulation, or memory uploading. Today, human body is a hybrid body, a border creature, opening all possible limit assumptions between human, non-human, and inhuman (Haraway, 1991; 2004). In this sense, the concept of cyborg symbolizes the rupture of those frontiers and can be critically used to establish a new concept of what it means to be human. In everyday life, this perspective allows us to think about our self or our hybrid condition in relation to everyday machines. It makes it possible for us to think about our connection with the digital artefacts which have already become body extensions. When connected in networks with such technological equipment, it becomes difficult for nurses to distinguish where the body ends and the machine begins. Despite the strangeness caused, this hybridism of the cyborg is already a reality (Rama, 2012).
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In clinical nursing settings, ‘machines’, particularly those used in advanced life support, end up becoming a second client for nursing care, because, like patients, they also need to be assisted, touched, and cared for. Lyra da Silva et al. (2009), in a study of the meaning of technology for nursing during the immediate postoperative stage of cardiac surgery, suggests that nurses deal with technological devices as if they were a part of a human body, not an extension of the patient, but the patient himself. Late twentieth-century machines have made thoroughly ambiguous the difference between natural and artificial, mind and body, self-developing and externally designed, and many other distinctions that used to apply to organisms and machines. Our machines are disturbingly lively, and we ourselves frighteningly inert.
(Haraway, 1991)
The paradigm of the cyborg ontology, which is fully assumed as a construct of nursing sciences, can mark the start of a meeting beyond the existing cleavage between person-centred care and aggressive biotechnologies. This allows us to update and contextualize the meaning of person-centred nursing care in the relational spaces of sophisticated technology (Lapum et al., 2012). Also, issues regarding the beginning and the end of human life, the borders of extending life by means of aggressive biotechnologies, the reconfiguration of biologically predetermined patterns, or the limits of body plasticity pose new questions about the meaning of person-centred care.
The rediscovery of an aesthetic knowledge in nursing Personalized, integral, and integrating nursing care has necessarily an aesthetic dimension, which organizes reality and reconstructs existential meaning.The aesthetic knowledge pattern has been reduced by some authors to slightly less than the ‘art’ of knowing how to perform the techniques or procedures, involves a deep appreciation of the meaning of a situation, and moves beyond the surface of a situation, bringing together all the elements of a nursing care situation to create a meaningful whole (Carper, 1978; Archibald, 2012). Aesthetic in this sense is used
to mean ‘relating to the here and now’, from the original Greek. Technical skills together with timing, personal integrity, and body coordination in nursing are an artistic performance which, apparently, does not require any effort (Peplau, 1988). We realize this intuitively while observing a nurse in the art of caring, in which the technical component is reconfigured by the ‘artisan’ knowledge. This is evident when we see the images of Sonia Rochel (2013) bathing a newborn child, when we witness a nurse caring for an elderly patient with sensitivity, or a nurse establishing a therapeutic bond by communicating with a severely mentally ill patient. The outside observer recognizes the aesthetic experience of care as a subjective, individual, singular, and unique knowledge but, at the same time, shareable and communal as an immersive sensorial aesthetic experience (Monteiro, 2014). In this sense, the aesthetics of care goes beyond the purely technical aspects, since it integrates the world of values, the feelings, and the ethical and cultural aspects which constitute the aesthetic experiences in nursing care processes (González & Ruiz, 2012). The poetic paradigm in nursing knowledge also deserves special attention. The poetic term ought to be understood in the original Greek meaning of poiesis, which means creation, creativity. Communication is at the core of nursing interventions, in its clinical praxis and in the specific type of scientific knowledge organized by nursing. If the aesthetic experience is an acute and active perception of the object or situation, only the aesthetic knowledge can allow for a unified and enhanced understanding of complex life situations and experiences in nursing care. Only aesthetic, creative, and ‘poietic’ nursing care can ‘illuminate’ and bring together the gap between aggressive biotechnologies, robotics, IT in healthcare, and person-centred care.
Conclusions The emerging multiparadigms, among which some are more traditional but have new reconfigurations, can lead to an identity dispersion of nursing knowledge if they are not reorganized within a more comprehensive model. The paradigm of totality is not completely useful, rather the opposite, for this epistemological
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matrix of nursing sciences. If the whole is not the sum of its parts, the part is not less than the whole. From this perspective, the whole is not more than the parts; it is less than the individual parts because each component of this dystopian reality has to be fully analysed in itself. Using evidence and standardized nursing language embedded in IT systems allows nurses and health care providers to act individually or collectively in performing a wide array of information creation and processing activities (Bakken & McArthur, 2001). However, computerized language in nursing care must be considered in connection with health biotechnologies. Also, the borderline languages and the affirmation of Humanity in nursing care are embedded in bioethical questions regarding body frontiers. Radical aesthetic transfiguration allowed by new ITs gives visibility to meaningful care in nursing practices. While advances in technology bring many benefits to both the patients and nurses, far from resolving the problems of scarce nursing resources, the use of robots raises profound psychological, philosophical, and spiritual questions for nursing practice (Metzler & Barnes, 2014). Therefore, a multiparadigmatic knowledge requires a reference point to confer a core role onto the kaleidoscopic knowledge in nursing and secure the radical affirmation of this kaleidoscopic knowledge as scientifically valid in its specificity. Without this core role, the nursing sciences are at risk of dystopian fragmentation, with no clearly defined identity borders. This is indeed what is happening today, with repercussions on the praxis, such as the functional overlapping between nursing and other biomedical professions which intervene in borderline areas and/or common clinical specialties. Despite the radical changes, it is possible to establish a unifying axis which defines the scientific identity of the nursing sciences. Historically, nursing encompasses a deep sense of human ethics in both the epistemological and anthropological meanings of the term (Teixeira, 2005; Rodrigues, 2007). Although this meaning was not based on a theoretical and conceptual framework, when nursing affirmed itself as an autonomous field of knowledge, this evidence became more and more solid. As
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a methodological, scientific, and poietic option, it gradually became evident that the nursing intervention is on the edge of human vulnerability. Nursing interventions are concerned with empowering people and helping them to achieve, maintain, or recover independence. This is not because nursing has an ontologically predetermined ‘salvific moral mission’. It is rather because nursing care finds itself always within a context of promotion of the human being, of the other’s potential, of intersubjective encounter, and of assistance for the essential human needs which are compromised by incidental or developmental processes. However, this notion of scientific knowledge in nursing, with the person-centred care as the object, has to include the new borders and transfigurations of the concepts of person and human being, brought about by the incorporation of biotechnologies and the digitalization of everyday life (Monteiro, 2013). The person now achieves a posthuman dimension, and the cyborg ontology will play a fundamental role in the epistemological conceptualization in nursing. The priority research issues in nursing should contribute to improving health and access to health care for socially and economically vulnerable people, physically and mentally impaired persons, minority group populations, and people who are socially excluded from the social contract. Research in nursing, which is contextualized and comprehensive from a phenomenological perspective, ought to be based on the multidimensionality of the cultural dimensions and the palimpsest of the culturally demarcated meanings of the concepts of health, wellbeing, happiness, comfort, pain, hope, lived body, illness, and death. The recent research lines in nursing reflect precisely these dimensions, as well as the use of qualitative and quantitative methodologies in scientific development, seeking to integrate the concepts of totality, concurrency, transformation, and transdisciplinarity (Morin, 2001). Therefore, the new epistemological proposals in nursing point towards not only new types of knowledge, but also new ways of producing knowledge. Scientific knowledge in nursing sciences refers to new epistemological approaches on a diatopical hermeneutics which allows the intercultural translation of multiple bodies of knowledge.
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Original article
Cyborgs, biotechnologies, and informatics in health care – new paradigms in nursing sciences Ana Paula Teixeira de Almeida Vieira Monteiro RN MSc PhD Adjunct Professor, Coimbra Nursing School; Researcher; Health Sciences Research Unit-Nursing, Coimbra, Portugal
Abstract
Nursing Sciences are at a moment of paradigmatic transition. The aim of this paper is to reflect on the new epistemological paradigms of nursing science from a critical approach. In this paper, we identified and analysed some new research lines and trends which anticipate the reorganization of nursing sciences and the paradigms emerging from nursing care: biotechnology-centred knowledge; the interface between nursing knowledge and new information technologies; body care centred knowledge; the human body as a cyborg body; and the rediscovery of an aesthetic knowledge in nursing care. Keywords: epistemology, biotechnology, computers, cyborgs.
Background Nursing is in a moment of paradigmatic transition, both in the epistemological and social dimensions. In this transition process, it is possible to glimpse epistemological alternatives and a new paradigm emerging from scientific knowledge, based on a broader rationality, the overcoming of the nature/society dichotomy, the complexity of the subject/object relationship, the approximation of pure sciences to humanistic studies, and a new connexion between science and ethics (Santos, 2010). Radical social transformation also challenges the reconstruction Note: This article is based on an article first published in Portuguese in the journal Pensar Enfermagem. Correspondence: Profª Doutora Ana Paula Teixeira de Almeida Vieira Monteiro, PhD, Adjun, Coimbra Nursing School, Avenida Bissaya Barreto – Apartado 7001, Coimbra 3046-851, Portugal. Tel.: 00351239 802 850/239 487 200; fax: 00351239 442 648/239 483 378; e-mail: [email protected]
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of nursing sciences in several domains: global population ageing; the epidemiological explosion of degenerative and mental illnesses; the aggressive medicalization of everyday life; and the crisis in the welfare state. The contemporary affirmation of Nursing Sciences arises from the intensive everyday life medicalization – the growing intervention of medicine in the most private domains of human experience (Crawford, 1980) and the biotechnological sophistication, which characterized the evolution of medicine throughout the 20th century. Over several decades, scholars have attempted to encompass the trinity of physical, psychological and social aspects of care in theories and models of nursing, which were intended to guide practice and provide a platform for training curricula and research, thus supporting the development of professional knowledge.
(McCrae, 2012)
The quest that began in the last quarter of the 20th century has been fostered by several factors, including
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nursing education’s move from the hospital to the academy, changes within nursing itself, and the feminist movement. In this process, nursing sciences has asserted itself scientifically and socially by its attachment to the mechanicist and organicist biomedical model, while paradoxically, the theoretical– conceptual nursing models proclaimed the holistic dimension of person-centred care. Adopting professional practice towards technical rationality, associated with the influence of taylorization, transformed nursing care into an essentially technical act, arising from the medical act (Amendoeira, 2004). The biomedical understanding of human illness and suffering is reflected in the material practices of the medical profession, which for over a period of two centuries has been able to establish its dominance within the evolving organizational system of health care (Crinson, 2007). The epistemological building of an autonomous knowledge in nursing was translated into a positivist and materialistic discourse, associated with the notion of clinical efficacy or the conceptual idea of evidencebased knowledge, and it was consolidated in the hospital settings of invasive technologies. In fact, the greater the complexity of health technologies and settings where nurses develop their practice, the higher is their professional status and the acknowledgement of their scientific potential. From ‘physicians’ assistants’ to ‘almost physicians’ or even ‘physicians’ substitutes’, nurses are performing roles that not so long ago were strictly reserved for the medical profession. However, the nursing interventions’ paradigms are only apparently changing while keeping the original hierarchical dependence of physicians’ power knowledge (Carapinheiro, 1993). One of the central issues in the literature is to know whether nursing science ought to be based on a multiparadigmatic epistemic structure, or on the contrary, the knowledge produced should be synthesized around a specific model, which would guide research and praxis. The current theoretical models of nursing sciences and the recent empirical research in this field refer to a multiparadigmatic epistemic substrate which includes both qualitative and quantitative approaches, and the integration of the complexity, simultaneity, and totality paradigms in the nursing
discipline (Parse, 1987; Kérouac et al., 1996; Cody, 2005; Struby, 2008). Multiculturalism, multiprofessionality, humanism, identity, autonomy, and excellence of care are today at the centre of the debate around the academic and professional components of the nursing discipline (Abreu, 2001; Monteiro, 2014). Monti & Tingen (1999) believe that multiple nursing paradigms allow for unconventional and new thinking, stimulating concepts, and a diversity of views. The current nursing paradigms undertaken by the scientific community as theoretical references for the development of the discipline set the discussion around the possibilities and scenarios of development that emerge where the limits of ‘normal science’ managed to silence other possible paradigms. It is Kuhn’s premise that science does not build upon itself in a linear progression. In normal science, the paradigm is already preformed, providing a foundation of theories, ontological assumptions, and procedures with which to work. In this sense, paradigms streamline the process of science, so long as normal science does not encounter major stumbling blocks that contradict its foundations (Kuhn, 1970). The new emerging paradigms, asserting themselves on other frameworks which, until now, could not be designed in nursing as a reflection in the strict limits of ‘normal science’, create a set of opportunities and challenges to the reconstruction of beliefs within the scientific community with regard to the conceptualization of reality in nursing (Irigibel-Uriz, 2010). Postnormal science paradigm (Funtowicz & Ravetz, 1993) opens the possibility for ‘narratives’ as a means of addressing complexity. Also in nursing sciences, narratives provide important additions to factual claims ‘because they are not about objective reality, but are statements of what is significant’ (Allen & Giampietro, 2006, p. 595). Nursing is hard to define as an autonomous science. As a result, it has a complex, fragmented identity. In this epistemological transition, there are some research lines and trends that anticipate the reorganization of Nursing Sciences, and the emerging of new paradigms in nursing care. This paper will be structured in the following way. Firstly, we will examine the theoretical debates within
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Nursing Sciences and the problems about how to integrate biotechnologies, robotics, and information technology (IT) into a coherent understanding of nursing care. Secondly, we will examine how the new paradigms emerging in Nursing Sciences (a biotechnologycentred knowledge; a person care-centred knowledge integrating the cyborg ontology, and a rediscovery of an aesthetic knowledge in Nursing) can contribute to a multiparadigmatic model, bringing together classic with postmodern paradigms of care.
A biotechnology-centred knowledge Nursing Sciences still adhere to a humanistic vision of technology, by classifying technology as non-human or non-natural, integrated into a conceptual vision where a cleavage between human/non-human and nature/technology occurs (Barnard & Sandelowski, 2001). Some empirical studies and theoretical conceptualizations describe nurses as the mediators or the bridge over the gap between aggressive technology and humanized therapeutic space. Therefore, nurses are responsible for maintaining health care humanity in technological environments (Halm & Alpen, 1993). However, both innovation and technological sophistication in health sciences, especially in hospital settings, have been growing so exponentially that the scientific discourse on the theme (humanized nursing care versus technologies) has undergone a subtle change. It is now considered that technological skills are absolutely essential for the provision of nursing care. Humanization of care necessarily implies the implementation of more aggressive technological environments (Lapum et al., 2012). Nurses are no longer the ‘mediators between two worlds’ but a structural element of biotechnologies applied to health care or disease processes. Technology, in particular those considered as ‘hard technologies’, is regarded as essential for the efficient provision of care and health assistance (Vargas, 2002). Nursing scientific discourse and research on the frontiers of care versus technology usually focus on intensive care units or emergency rooms – settings where high technological sophistication and use of intensive technology to carry out diagnoses and therapeutics are central. The nature of the work
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developed in these units focuses on specialization, requiring highly elaborate and accurate work instruments and procedures, where a central role is played by technological equipment. This leads to strictly technical and mechanistic activities, in which the nurse focuses on the area of technology related to the patient and invasive activities, putting deep relationships between nurse and patient/family in the background (Saiote, 2013). There are already some experiences involving biological connections and computer systems, digital interfaces between living tissues. Some standardized technological artefacts of homogenization and control can be used by nurses in their daily clinical practice. The actual trend is the ‘robotization’ of tasks that are classically considered as nursing responsibilities or tasks that are usually mediated by nurses (e.g. assessing, measuring, and monitoring vital signs). Robots are currently being developed to assist the elderly and people with motor disabilities in some activities of daily living.In fact,the expression nurse robot is becoming a clinical reality: Experimental studies are still being carried out on prototypes, and they are having some impact in Japan. In some units, nurses are already being replaced by robots. New technology in Japan has resulted in a kind of robot intelligence known as ‘kansei’ (Ken-Zi), which literally means ‘emotion or feeling’. Kansei robots monitor human expressions, gestures, and body language and listen to people. They also sense human emotion through sensors that monitor pulse rate and perspiration (Huston, 2014). We are beginning to understand the apprehension concerning the way in which life-like robots are being introduced for the care of older adults. In the process of our interactions with these artefacts we could progressively experience transformations in our basic understandings of ourselves – transformations deep enough to merit our serious attention while we still are capable of distinguishing the alternatives’. (Metzler & Barnes, 2014, p. 13)
Interface between nursing knowledge and new ITs The ever-evolving, technology-intensive nature of the 21st century health care has caused acceleration in the
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division of labour, whereby work practices are becoming highly specialized, and the communication of knowledge is in a constant state of flux (Ludvigsen et al., 2011). This poses a challenge for education and learning in nursing. New information and communication technologies are drastically reconfiguring the way scientific knowledge in nursing is constructed and disseminated.They are also making profound changes in the nursing planning, operationalization, and sense of caring in clinical settings. Nowadays, in developed countries, nursing education is mostly based on the implementation of teaching–learning models where IT platforms, e-learning, and virtual information are in the front line. The dissemination of learning processes through the use of clinical practice laboratories in virtually simulated environments or with IT application models represents a new approach of pedagogical methodologies in nursing (Luzio, 2006). In these learning processes, human mediation and faceto-face contact tend to become scarcer, fragmented, and almost non-existent in some areas of nursing education. Also in clinical practice, IT systems that support nursing practice are revolutionizing the way in which nursing care is structured, operationalized, implemented, and assessed (Dreyfus, 2001). The implementation of IT systems in nursing (Support System for Nursing Practice) required a profound redefinition of the activities developed in the course of the provision of nursing care to the client, implying new forms of interaction, sociability, and reorganization of control mechanisms. The main features provided by IT systems allow nurses to register interventions resulting from medical prescriptions, data resulting from nursing assessment, and nursing interventions or care plans. However, computer language itself is a challenge to autonomous reflexivity in clinical practices and counteracts holistic approaches to care – the essence of nursing (Collière, 1996). Even though it was built from the biomedical model, the affirmation of nursing as a ‘profession’ has always used other languages, which are also procedures in context, rooted in this central concept of care. Is the computer language applied to health systems and nursing classifications reconfiguring the essence of care? Will it be a kind of care robotization, in which
the humanization has to be put aside permanently in favour of effectiveness rankings and invasive intensive technology? How is this expressed in language? Some authors have questioned whether standardized nursing diagnoses may be a restrictive, objectifying, and alienating option of the biomedical model. Does a methodology that involves the reductive fragmentation of the person to problem-type computerized ‘diagnosis’ not imply overlooking the fact that reality is holistic, and analysing problems outside the context that provides them with meaning? (Moya, 2006). The attempt to computerize nursing care has resulted in the International Classification for Nursing Practice (ICNP®), drawn up by the International Council of Nurses, with the purpose of standardizing scientific terminologies used in nursing, by gathering the diagnoses, interventions, and outcomes of nursing practice. The aim was to establish a common language, allegedly universal, to describe and document nursing practices, providing nurses with a vocabulary which could be used to include nursing data in IT systems. The ICNP has been presented as an instrument for facilitating communication among a professional group, or among the actors of the health system, possibly improving the quality and effectiveness of care. It is also assumed in several national and international documents that the information resulting from nursing data recorded using the ICNP can be used to plan and manage nursing care, in financial forecasts, to analyse patient outcomes, and to develop health policies (International Council of Nurses-ICN, 2005; Ordem dos Enfermeiros (OE), 2009). Due to its nature, the characteristics of the standard classification of care systems and nursing interventions with the aim of transforming them into computerized language cannot include too many details. The ultimate goal is to build databases that allow the digital archive of information that is very close to the statistical description of simplified task listings. This means that the notion of nursing care is drawing closer to the statistical concept. There is, therefore, an insolvable paradox in the process of computerization of nursing care parameters and nursing prescriptions. It was not the com-
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puter language and informatics programming that were adapted to nursing care models and their theoretical background. It was precisely the opposite. Computer language, which is, by definition, simplistic, fragmentary, descriptive, task-based, and limited to the performance of biomedical techniques, has overlapped reflexivity, the holistic dimensions, and complexity of the concept of nursing care. There is growing evidence that computer ratings cannot translate the specific practices and knowledge of nursing professionals, and they do not automatically imply an effective improvement of care (Pozo, 2013). Even more radical are the cleavage and the transcultural inadequacy if we think about language as being based on experiential concepts of intersubjectivity. The ICNP nursing diagnoses are no longer based on the model of basic needs or levels of dependence as in the previous rating models; instead, they have adopted a terminology that arises from the biomedical model which is limited to a group of clinical symptoms. The medical and the nursing diagnoses become almost overlapped in terms of language, meaning, and lack of differentiation. First of all, the new ITs applied to health care are also systems to access, search, process, use, and disseminate information. They work as support mechanisms for the implementation of new management models and approaches in an essentially economicbased and business model (Cunha-Filho, 2003). In the structural organization of health services, informatics processes are targeted to the standardization and control of nursing care in a perspective of information archive in databases, having the tayloristic division of work and the notion of task work as conceptual models. However, the computer revolution goes beyond technological equipment management (correlated with intensive biotechnologies) or clinical information management systems. We are still at an early stage. The aggressive digitalization of everyday life (Monteiro, 2013) in health associated with the exponential technological innovation and artificial intelligence (computers that learn by themselves) is a growing reality. Another important dimension has to do with clinical prescription decisions. The nursing judgement, diagnostic formulation, and prescription
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of interventions will be carried out by computing systems with no human mediation, as is the case with other decision-making scenarios in hypercomplexity contexts (Harper et al., 2008).
A body care-centred knowledge: the human body as a cyborg body Nursing sciences have focused their epistemological construction in person centred (body to body, skin to skin, and face to face) care where the human body is seen as a central artefact of the very notion of humanitude. However, the radical innovations of biotechnologies and new information systems in health imply the reinvention of body-centred care. The concept of cyborg is particularly important when discussing the emergence of new forms of scientific knowledge in nursing.A cyborg is a cybernetic organism, a hybrid of machine, and a biological organism, which incorporates the human and the non-human, the ‘natural’ and the ‘artificial’, but at the same time, it assumes a new entity which is irreducible to any dualism or hierarchy (Haraway, 1991). Nowadays, the human body moves within a new frontier: the space for the dematerialization into a prosthetic body, a space for postbiological and posthuman aesthetic, a space for cloning, replication, robotics, human action simulation, or memory uploading. Today, human body is a hybrid body, a border creature, opening all possible limit assumptions between human, non-human, and inhuman (Haraway, 1991; 2004). In this sense, the concept of cyborg symbolizes the rupture of those frontiers and can be critically used to establish a new concept of what it means to be human. In everyday life, this perspective allows us to think about our self or our hybrid condition in relation to everyday machines. It makes it possible for us to think about our connection with the digital artefacts which have already become body extensions. When connected in networks with such technological equipment, it becomes difficult for nurses to distinguish where the body ends and the machine begins. Despite the strangeness caused, this hybridism of the cyborg is already a reality (Rama, 2012).
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In clinical nursing settings, ‘machines’, particularly those used in advanced life support, end up becoming a second client for nursing care, because, like patients, they also need to be assisted, touched, and cared for. Lyra da Silva et al. (2009), in a study of the meaning of technology for nursing during the immediate postoperative stage of cardiac surgery, suggests that nurses deal with technological devices as if they were a part of a human body, not an extension of the patient, but the patient himself. Late twentieth-century machines have made thoroughly ambiguous the difference between natural and artificial, mind and body, self-developing and externally designed, and many other distinctions that used to apply to organisms and machines. Our machines are disturbingly lively, and we ourselves frighteningly inert.
(Haraway, 1991)
The paradigm of the cyborg ontology, which is fully assumed as a construct of nursing sciences, can mark the start of a meeting beyond the existing cleavage between person-centred care and aggressive biotechnologies. This allows us to update and contextualize the meaning of person-centred nursing care in the relational spaces of sophisticated technology (Lapum et al., 2012). Also, issues regarding the beginning and the end of human life, the borders of extending life by means of aggressive biotechnologies, the reconfiguration of biologically predetermined patterns, or the limits of body plasticity pose new questions about the meaning of person-centred care.
The rediscovery of an aesthetic knowledge in nursing Personalized, integral, and integrating nursing care has necessarily an aesthetic dimension, which organizes reality and reconstructs existential meaning.The aesthetic knowledge pattern has been reduced by some authors to slightly less than the ‘art’ of knowing how to perform the techniques or procedures, involves a deep appreciation of the meaning of a situation, and moves beyond the surface of a situation, bringing together all the elements of a nursing care situation to create a meaningful whole (Carper, 1978; Archibald, 2012). Aesthetic in this sense is used
to mean ‘relating to the here and now’, from the original Greek. Technical skills together with timing, personal integrity, and body coordination in nursing are an artistic performance which, apparently, does not require any effort (Peplau, 1988). We realize this intuitively while observing a nurse in the art of caring, in which the technical component is reconfigured by the ‘artisan’ knowledge. This is evident when we see the images of Sonia Rochel (2013) bathing a newborn child, when we witness a nurse caring for an elderly patient with sensitivity, or a nurse establishing a therapeutic bond by communicating with a severely mentally ill patient. The outside observer recognizes the aesthetic experience of care as a subjective, individual, singular, and unique knowledge but, at the same time, shareable and communal as an immersive sensorial aesthetic experience (Monteiro, 2014). In this sense, the aesthetics of care goes beyond the purely technical aspects, since it integrates the world of values, the feelings, and the ethical and cultural aspects which constitute the aesthetic experiences in nursing care processes (González & Ruiz, 2012). The poetic paradigm in nursing knowledge also deserves special attention. The poetic term ought to be understood in the original Greek meaning of poiesis, which means creation, creativity. Communication is at the core of nursing interventions, in its clinical praxis and in the specific type of scientific knowledge organized by nursing. If the aesthetic experience is an acute and active perception of the object or situation, only the aesthetic knowledge can allow for a unified and enhanced understanding of complex life situations and experiences in nursing care. Only aesthetic, creative, and ‘poietic’ nursing care can ‘illuminate’ and bring together the gap between aggressive biotechnologies, robotics, IT in healthcare, and person-centred care.
Conclusions The emerging multiparadigms, among which some are more traditional but have new reconfigurations, can lead to an identity dispersion of nursing knowledge if they are not reorganized within a more comprehensive model. The paradigm of totality is not completely useful, rather the opposite, for this epistemological
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matrix of nursing sciences. If the whole is not the sum of its parts, the part is not less than the whole. From this perspective, the whole is not more than the parts; it is less than the individual parts because each component of this dystopian reality has to be fully analysed in itself. Using evidence and standardized nursing language embedded in IT systems allows nurses and health care providers to act individually or collectively in performing a wide array of information creation and processing activities (Bakken & McArthur, 2001). However, computerized language in nursing care must be considered in connection with health biotechnologies. Also, the borderline languages and the affirmation of Humanity in nursing care are embedded in bioethical questions regarding body frontiers. Radical aesthetic transfiguration allowed by new ITs gives visibility to meaningful care in nursing practices. While advances in technology bring many benefits to both the patients and nurses, far from resolving the problems of scarce nursing resources, the use of robots raises profound psychological, philosophical, and spiritual questions for nursing practice (Metzler & Barnes, 2014). Therefore, a multiparadigmatic knowledge requires a reference point to confer a core role onto the kaleidoscopic knowledge in nursing and secure the radical affirmation of this kaleidoscopic knowledge as scientifically valid in its specificity. Without this core role, the nursing sciences are at risk of dystopian fragmentation, with no clearly defined identity borders. This is indeed what is happening today, with repercussions on the praxis, such as the functional overlapping between nursing and other biomedical professions which intervene in borderline areas and/or common clinical specialties. Despite the radical changes, it is possible to establish a unifying axis which defines the scientific identity of the nursing sciences. Historically, nursing encompasses a deep sense of human ethics in both the epistemological and anthropological meanings of the term (Teixeira, 2005; Rodrigues, 2007). Although this meaning was not based on a theoretical and conceptual framework, when nursing affirmed itself as an autonomous field of knowledge, this evidence became more and more solid. As
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a methodological, scientific, and poietic option, it gradually became evident that the nursing intervention is on the edge of human vulnerability. Nursing interventions are concerned with empowering people and helping them to achieve, maintain, or recover independence. This is not because nursing has an ontologically predetermined ‘salvific moral mission’. It is rather because nursing care finds itself always within a context of promotion of the human being, of the other’s potential, of intersubjective encounter, and of assistance for the essential human needs which are compromised by incidental or developmental processes. However, this notion of scientific knowledge in nursing, with the person-centred care as the object, has to include the new borders and transfigurations of the concepts of person and human being, brought about by the incorporation of biotechnologies and the digitalization of everyday life (Monteiro, 2013). The person now achieves a posthuman dimension, and the cyborg ontology will play a fundamental role in the epistemological conceptualization in nursing. The priority research issues in nursing should contribute to improving health and access to health care for socially and economically vulnerable people, physically and mentally impaired persons, minority group populations, and people who are socially excluded from the social contract. Research in nursing, which is contextualized and comprehensive from a phenomenological perspective, ought to be based on the multidimensionality of the cultural dimensions and the palimpsest of the culturally demarcated meanings of the concepts of health, wellbeing, happiness, comfort, pain, hope, lived body, illness, and death. The recent research lines in nursing reflect precisely these dimensions, as well as the use of qualitative and quantitative methodologies in scientific development, seeking to integrate the concepts of totality, concurrency, transformation, and transdisciplinarity (Morin, 2001). Therefore, the new epistemological proposals in nursing point towards not only new types of knowledge, but also new ways of producing knowledge. Scientific knowledge in nursing sciences refers to new epistemological approaches on a diatopical hermeneutics which allows the intercultural translation of multiple bodies of knowledge.
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