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Shaping technologies in practice. A short review of “Care at a distance” by Jeannette Pols

The term telecare refers to technical devices and professional practices applied in the so-called remote assistance, to support chronic patients living at home.

How telecare takes shape in care practice is at the centre of Care at a distance, by Jeannette Pols: through detailed ethnographic research in the Dutch context, the author investigates on how telecare changes care relations between nurses and patients living at home, and how local practices of care in turn shape technology.

According to Pols, there are mainly two conflicting opinions on telecare, and in general on the employment of new technologies in the Dutch care field: on the one hand, those who see telecare as fundamental – given the increasing number of elders with chronic diseases and the lower availability of people taking care of them – while reducing the cost of healthcare. On the other hand, there are those arguing that telecare and technology will increase the isolation of older people, surrounded by “cold devices” and deprived of warm human contact. The fact that telecare is available in different forms (such as webcams, monitoring or “smart” devices) with equally different uses and possibilities and has several potential users (patients and their families, healthcare professional and organizations) further complicates this debate.

Pols underlines that these different positions create a juxtaposition between “inevitable scenarios”: the “optimists” accusing the “pessimists” of obstructing a great future in healthcare, and the pessimists blaming the optimists for imposing a technology that will lead to neglect the patient.

Pols’ study represents an alternative in addressing technological innovations in the context of care, analyzing and comparing different telecare practices that are pioneering in the Netherlands, through an ethnographic approach.

Ethnography allows the researcher to ask open questions. Through it, Pols analyzes new devices and people as the results of specific local practices. Furthermore, ethnography permits to reveal concerns and values shaping telecare devices in everyday life, critically articulating the theories that shape our vision of care and technology (for instance, the assumption that technology does determine a situation is embedded in both the aforementioned positions in telecare debate).

Telecare developers target people with chronic illness (COPD, heart failure and diabetes) most of the time, as they form the most significant group of patients; furthermore, palliative care is a new branch in Dutch telecare.

Consequently, the study focused on various care practices: a telecare project in palliative care for cancer patients, webcams used to provide professional support to people with COPD, call centre nurses monitoring vital signs of people with severe heart failure.

This range of practices implies that treatments take place in various forms: it differs between people with different illnesses, but also between configurations of patients, professionals and devices within the same “group”. In particular, patients use and develop practical experience enabling them to live coping with illness: they assemble and adapt received knowledge to their situation, finally creating this practical knowledge. As argued by Pols, this variety makes innovative telecare an excellent context to learn about care.

Studying telecare project in palliative oncology allows Pols to analyze the opposition between warm treatment and cold technology.

Generally, warm attention refers to good care for patients as a subject, on the contrary, cold care concerns to technical and medical care for patients as an object. However, Pols’ research showed that “temperature” metaphors are not particularly suitable for recognizing good from bad cures. As the author notes, technology is particularly cold: one of the main concerns is that technology will replace human beings and contact, reducing care to mechanical interactions with machines and pushing those already without social contact to lose even more when technology takes over human tasks. Still, how does this image of technology is involved in telecare practices?

In Pols’ research on telecare in palliative oncology, patients do not consider devices as “separated”, but as a part of the care they are receiving; for instance, some devices are thought to help them to find a “new order” in the chaos caused by their situation. In some cases, the device, with the regularity of its requests for attention, contributed to the taming of disease and to the construction of time and space for an ordinary life. Pols’ informants also emphasize telecare’s ability to bring people – patients, caregivers and nurses – together, reinforcing already good bonds.

Some patients stress the fact that even human relations cannot always be considered warm: for instance, some relationships break down at the beginning of the disease, or it is possible to meet indifferent professionals.

As pointed out by the author, warm care needs good relations. Simply setting warm against cold, or subjective versus objective can be problematic. Care is good when trying to adapt the personal situation of the single patient: Good care requires warmth and coldness, knowledge and empathy, but carers need to mix them in quantities that fit the particular and temporary situation of individual patients. Personalization must be a feature of the care relationship between patients, caregivers, professionals, and device.

The goodness of the intervention is contingent on the relationship. Neither warmth nor coldness has a predefined meaning: both technical and human responses can be suitable, as long as they adapt. Adaptation is a relational activity, a way of interacting that must continuously be established, rather than an effect of the machines.

Knowing patients can not be done without considering their experience, continues Pols: respect comes from taking their treatment seriously and knowing when to apply empathy or when painkillers are the best option. In engaging professionally in care, ethics and knowledge do not exist separately. Instead of separating and contrasting warm and cold, ethics and knowledge, Pols suggests a third metaphor to overcome these oppositions: the metaphor of fitting.

As noticed by Pols, technology can be understood as caring or not. Medical technologies aim to transform the patient’s condition to improve it, but device designers and engineers cannot control their “effects”: the role of patients and their caregivers, and their ideas about care and how they engage relations with technology, need to be taken into account to understand technology in practice.

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