Abstract/Summary

This thesis chronicles the five-year development of PreCare, a telemedicine project, initiated by a Danish hospital from inception to completion, using a longitudinal Action Research (AR) approach. The project aimed to empower citizens living with chronic diseases to actively manage their conditions. The telemedicine process relocated care from hospitals to citizens’ homes, where they used digital devices to monitor their vitals and adjust behaviours in response to deteriorating conditions. The research team involved in PreCare, initially, emphasized empowering citizens to become more health-literate and autonomous, in line with prior research (Greenhalgh et al., 2017). However, unexpected findings emerged during intense reflection by the AR team, revealing that PreCare’s success relied on citizens becoming more dependent on healthcare services. This paradox highlighted a deeper societal issue: the challenge of understanding and harnessing innovations like PreCare within an individualistic framework. The thesis argues that PreCare’s success was due to a new, socially distributed system of enacting care, rather than transferring more capabilities to the individual (Mol, 2008). This contrasts with prior person-centric research that attributes these outcomes to the personal attributes of nurses and citizens, such as the nurses’ compassion and expertise and the citizens’ growing autonomy and health literacy. The abduction process as a method of inquiry enhanced the AR process, weaving data and theory into interpretations that continually propelled the project forward, demonstrating the dynamic nature of AR (Coghlan and Brannick, 2014). The abductive logic of inquiry used in AR makes it possible to draw on theory in the light of the evolving nature of the findings from practice. This encouraged everyone involved to reflect the assumptions framing their conceptualisation of the problem The AR process facilitated the evolution of PreCare from a person-centric care model within the framework of biopsychological medicine to biopsychosocial medicine. This transition promoted an integrated care approach combining medical, psychological, and social interventions, leading to a more comprehensive, system-centric management of chronic conditions (Bolton and Gillett, 2019). AR challenged the decontextualized, biopsychological perspective, which conceptualized the person as an individualized set of experiences and preferences, in favour of socially patterned influences on the person and health in accordance with biopsychosocial medicine (Engel, 1977). This innovative approach to socially distributed medical services is essential for exploring new methods of chronic care management. The thesis illustrates how citizens’ health outcomes improved by participating in a socio-material system that integrates nurses, technology, and citizens collaboratively working to prevent the worsening of their chronic conditions. This aligns with Foucault’s concept of biopower, where power and capability are distributed across a socio-material system (Lynch, 2016). The thesis also explores how societal changes have transformed the home into a critical space for managing population health. Techniques used by nurses to create and maintain the revised chronic care included reframing patients to be “citizens,” conducting constant surveillance with pastoral power, leading to normalization of behaviours (Foucault, 1977). The transformation relied on citizens internalizing PreCare standards by adopting the collective’s norms as their own. Consistent with Foucault’s ideas on biopower, this internalization occurs when individuals believe others have constant oversight, based on their self-reported data and frequently follow-up on non-compliance with prescribed behaviour. This exercise of biopower avoids deteriorating health conditions (Foucault, 1977). One key finding was the use of constant surveillance, pastoral power, and normalization to follow collective behavioural prescriptions. This approach minimized healthcare costs (Foucault, 1977) and improved patient experiences. Another significant finding is that Precare reconceptualizes the nursing role by showing that caring and coercion are not mutually exclusive. Precare nurses' practice of "compassionate coercion" using disciplinary power to train citizens in self-regulation freed up collective resources and further transformed the role of doctors. The biopower concept brought to light the political goals that motivated PreCare interventions (Foucault, 2003). Understanding these goals matters because it changes how power operates, including analytic attention to power’s productive and socially distributed aspects (Foucault, 2003).