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Keywords:

  • cancer care;
  • Foucault;
  • health care;
  • nursing;
  • power;
  • technology

Abstract

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Implications for practice and/or policy
  6. Introduction
  7. Background
  8. The study
  9. Findings
  10. Discussion
  11. Conclusion
  12. Funding
  13. Author contributions
  14. References

Title. The use of technology in cancer care: applying Foucault’s ideas to explore the changing dynamics of power in health care.

Aim.  This study is a report to identify the utility of a hand-held side-effect monitoring system for people receiving chemotherapy in the home care setting.

Background.  Increasingly, health care is being provided in people’s own homes and communities rather than in hospitals. This has driven the development of technologies which support patients in the home environment. The meaning of such technologies can be explored from a Foucauldian perspective to shed light on how they enable new forms of medical surveillance.

Method.  An intervention study was performed in 2006 using new technologies for people receiving chemotherapy. Questionnaires were completed by 56 people affected by cancer who used the new technology; 12 of these people were then interviewed. Secondary analysis of the interview data is presented in this paper, drawing on Foucault’s writing about surveillance and power in medical settings.

Findings.  The interview transcripts contain numerous examples of people affected by cancer reflecting on issues such as power and surveillance in cancer care. While these terms are ordinarily considered to reflect negative elements of care, they were used by participants in an empowering manner.

Conclusion.  Theoretical insights can help nurses to think critically about the advances of technology. In particular, there are implications for how nurses consider the relationship of technology to patients and for power dynamics in healthcare relationships. We suggest that there is a need to problematize and celebrate the growth of technologically-driven health surveillance.


What is already known about this topic

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Implications for practice and/or policy
  6. Introduction
  7. Background
  8. The study
  9. Findings
  10. Discussion
  11. Conclusion
  12. Funding
  13. Author contributions
  14. References
  • Ways are increasingly being found in policy and practice to facilitate the care of patients in their own homes.
  • Advances in technology have enabled people to receive treatment such as chemotherapy at home.
  • The theories of Michel Foucault have been applied to problematize medical encounters.

What this paper adds

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Implications for practice and/or policy
  6. Introduction
  7. Background
  8. The study
  9. Findings
  10. Discussion
  11. Conclusion
  12. Funding
  13. Author contributions
  14. References
  • Foucault’s theories of power and surveillance offer a way of understanding and responding to changes in healthcare technology.
  • Patients receiving cancer care at home reported positive perspectives on the use of healthcare technology, thereby subverting the idea of surveillance as negative.
  • Further uptake of health surveillance technologies, which enable people to remain in their own homes during treatment, are likely to be well-received.

Implications for practice and/or policy

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Implications for practice and/or policy
  6. Introduction
  7. Background
  8. The study
  9. Findings
  10. Discussion
  11. Conclusion
  12. Funding
  13. Author contributions
  14. References
  • The use of Foucauldian theory should be considered in policy and practice to examine the accounts of people using cancer care to develop in-depth understanding of their experiences.
  • Practitioners should remain vigilant about the negative connotations of power and surveillance, ensuring that each technological innovation is critically examined from a patient viewpoint.

Introduction

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Implications for practice and/or policy
  6. Introduction
  7. Background
  8. The study
  9. Findings
  10. Discussion
  11. Conclusion
  12. Funding
  13. Author contributions
  14. References

Health care is increasingly being provided in people’s own homes and communities, rather than in acute care settings, as part of policy objectives to shift the balance of care. This has driven the development of ‘e-health initiatives’ (new technologies), which support the delivery of care by secondary and tertiary service providers in the person’s own home or locality, nationally and internationally (Mooney et al. 2002, Velikova et al. 2004, Basch et al. 2005).

Cancer services offer a useful case study for investigating the impact of this phenomenon, as treatments are increasingly being delivered at home. This means that patients are managing the majority of treatment side-effects without the direct support of healthcare professionals (McCaughan & Thompson 2000). In the United Kingdom (UK), in the Cancer Reform Strategy it is noted that the delivery of outpatient chemotherapy is increasing (Department of Health 2007), and this restructuring of cancer services (Scottish Executive 2005) has a direct impact on the management of treatment-related symptoms.

Communication technologies are being offered to help manage treatment-related symptoms in the community. The need for such symptom support is particularly acute in remote and rural settings where specialist medical personnel are not readily accessible (Roine et al. 2001). Technology promises ‘real time’ communication between patients within their local settings and their healthcare providers (Scottish Executive 2005). Indeed, this embrace of technology as health surveillance fits current constructions of patients as agentic in healthcare policy, which is pertinent across international boundaries where technology is increasingly being used, for example in England (Department of Health 2005), the United States of America (FDA 2005; National Institute for Health 2007), Canada (Health Canada 2007) and Australia (Thomson 2002; Australian Council for Safety and Quality in Health Care 2005) and in practice in the form of patient decision-making (Degner et al. 1997) and self-care (Dodd & Miaskowski 2003). The implications may be particularly salient for cancer care professionals in countries where the population is geographically dispersed, such as Australia and Canada. In these contexts, grappling with the meaning of technology for patients and the shifting dynamics of power will be particularly acute, and the provision of high quality remote and rural care is supported by surveillance medicine.

Many such technologies have been positioned as ‘patient driven’, meaning that the patient becomes responsible for reporting symptoms. This type of technology has predominantly been used in home-based care of people with chronic diseases such as chronic heart failure, asthma and diabetes (Biermann et al. 2002,Louis et al. 2003; Chumbler et al. 2005, Rasmussen et al. 2005, Barnett et al. 2006). There is also a growing emphasis on using these approaches with people affected by cancer (Mooney et al. 2002, Maguire et al. 2005).

Background

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Implications for practice and/or policy
  6. Introduction
  7. Background
  8. The study
  9. Findings
  10. Discussion
  11. Conclusion
  12. Funding
  13. Author contributions
  14. References

e-Health and cancer care

Chemotherapy is one of the primary treatment modalities in cancer care. Side-effects such as nausea, vomiting, fatigue, diarrhoea and neutropenia are common, some of which can be life-threatening (Richardson & Ream 1996, Du et al. 2002, Dranitsaris et al. 2005, Chen-Hardee et al. 2006, Kuderer et al. 2006). Thus, effective monitoring and management of patients’ symptoms is critical in preventing severe toxicities and their consequences.

However, symptoms in people with cancer are often poorly assessed and managed (National Institute for Health, 2002), and factors such as inadequate patient–provider communication and poor symptom assessment have been cited as contributory factors (Donovan et al. 2005, Cheville et al. 2008).

Researchers report improvements in quality of life and symptom control as a consequence of using technology to communicate between patients and healthcare professionals, reductions in the rate of hospitalizations, emergency department visits and cost savings (Louis et al. 2003). Patients also appear to have positive views of using this type of technology, reporting improvements in communication with healthcare providers (Maguire et al. 2005, Kearney et al. 2006).

The Advanced Symptom Management System (ASyMS©)

The ASyMS© system is an example of the use of technology in cancer care, which has been trialled in Scotland (Kearney et al. 2003). It is a mobile telephone-based remote symptom monitoring system which is used to log and manage the side-effects of chemotherapy in the home care setting (Kearney et al. 2000, 2003, 2006, Maguire et al. 2005). Patients using the system complete a symptom questionnaire on a mobile phone twice daily at home and send this information directly to their hospital-based healthcare professional. Self-care advice is then offered, linked to the symptoms reported. If the patient reports worrying symptoms, an alert (either amber or red, depending on the seriousness of symptoms) is generated to the healthcare professional based at the hospital via a 24 hour dedicated pager system. The healthcare professional can then view the symptoms that the patient has just reported via a secure webpage and contact the patient as appropriate. One healthcare practitioner has the ability to monitor multiple patients at a time through this system.

Foucault and the technologization of health care

While technological advances have been welcomed by healthcare providers, notions of surveillance (i.e. using technology to ‘keep an eye’ on or monitor people who are not physically present in hospital) are brought into play, indicating that a Foucauldian analysis may shed important and interesting light on the topic. The importance of Foucault’s work lies in the challenges it poses for many of the otherwise taken-for-granted aspects of contemporary health care, for example the notion that doctors are the unassailable authorities in illness (Cheek & Porter 1997).

Power and knowledge are two central themes in Foucault’s writing, and they create and reinforce each other. Power and knowledge are intimately woven together within new systems that use technology to perform observations from a distance.

A number of researchers have made use of Foucault’s work. For example, May (1992) explores the ways in which nurses’ accounts of their work and relationships with patients reflect a social discourse. Henderson (1994) examines patients in intensive care and the power of medical practices in shaping knowledge, thereby dictating and limiting the quality of nurse–patient relationships. Heartfield (1996) explores the discursive construction of the patient and the invisible nurse, while Cotton (2001) draws on Foucauldian concepts of power–knowledge and discourse to interrogate conceptualizations of reflection and reflective practice in contemporary nursing literature.

Surveillance in health care has been discussed as an extension of the ‘medical eye’ (Armstrong 1995, p. 400). Armstrong documents a progression in the formulation of health and illness in medicine, moving from bedside to hospital to laboratory medicine. An expansion of the hospital and laboratory approaches incorporates ‘surveillance medicine’, focusing on health-status monitoring.

From a Foucauldian perspective, ASyMS© and other similar systems, act out the micro power structures operating within health care. This focus on micro (rather than macro) power structures illuminates the everyday and routinized uses of power in people’s lives. The body (and particularly the sick body) is subject to such power. Indeed, as one commentator on Foucault suggests: ‘the body itself is invested by power relations’ (Rabinow 1991, p. 171), and new technologies are methods that contribute to how people are made subjects and potentially subjugated within the healthcare system.

In Foucault’s work, the body is drawn into and disciplined by the machinery of politics. He describes this as ‘bio-power’, and suggests that bodies are carefully regulated and controlled:

[the body’s] supervision was effected through an entire series of interventions and regulatory controls: a biopolitics of the population. (Foucault 1979, p. 139, original emphasis)

Thus, there is potential for exploring how such regulatory controls and supervision is operationalized, and how power is wielded and negotiated within health care when new technologies are applied.

Foucault (1993) develops a theory of the medical gaze, where person and disease are separated and only the physical is attended to and observed. Surveillance is a key component of this. Twigg suggests that ‘the medical encounter is the supreme example of surveillance’ (Twigg 2000, p. 12). As applied to e-health and cancer care, this means that healthcare practitioners exert power through their role as observers of the body. They have a specific medically-oriented regard towards monitoring the disease. This medical gaze is one way in which power is acted out and how ‘docile bodies’ are created. Use of the terms power, surveillance and docile imply moral objections, but Foucault argues that they are neither good nor bad. Indeed, the term ‘docile’ is not used in its everyday meaning, but a specific technical one. Disciplinary practices create a context for a ‘docile’ state to emerge. This is typified in the caricature of the submissive patient, lying silently (for fear of interrupting) during a ward round, while physicians conduct their observations and discuss the nature of the disease and treatment. Observation and control are both critical components in producing docile bodies, and the notion of internalizing the locus of power drives this. In the caricature presented above, this internalization is acted out by the patient’s submissive and silent role in the consultation, indicating that they understand the medical power dynamic, that it is the physician wields the power in the interaction.

Foucault (1979) develops and discusses this notion of the docile body in theorizing the domination and disciplinary practices over people, and the extent to which the body ‘may be subjected, used, transformed and improved’ (Rabinow 1991, p. 180). The role of observation and surveillance is critical here. He describes medical perception involving ‘initiating the endless task of understanding the individual’ (1973/2003, p. 15) and disaggregating the component parts of the embodied illness. He warns that:

Doctor and patient are caught up in an ever-greater proximity, bound together, the doctor by an ever-more attentive, more insistent penetrating gaze. (pp. 15–16)

Foucault’s work can thus be read as a warning about the adoption of practices which would further extend the medical gaze. The use of technology in supporting the implementation of a policy – delivering care in people’s homes and communities – has a potentially troubling outcome for patients.

As policy is rolled out, however, technologies will increasingly be used to support patients in their local settings and to promote an anticipatory and preventive model of care. Technology, as part of healthcare delivery, might be considered as:

A reorganization in depth, not only of medical discourse, but of the very possibility of a discourse about disease (Foucault 1973/2003, p. xxi)

Use of these technological systems simultaneously recruits patients as both objects and instruments of power through observation and self-surveillance. Foucault’s description of technologies of power in prisons exemplifies the way in which the observed are recruited into self-surveillance:

The perfection of power should tend to render its actual exercise unnecessary; that is this architectural apparatus should be a machine for creating and sustaining a power relation independent of the person who exercises it; in short, that the inmates should be caught up in a power situation of which they are themselves the bearers. (Foucault 1977, p. 201)

Drawing on ideas developed from Bentham’s panopticon, Foucault (1977) prioritizes notions of surveillance which are relevant to current e-health strategies. For example, the use of the ASyMS© system could be understood as centralizing and normalizing layers of medical surveillance. Surveillance is orchestrated through environmental manipulations, which might be considered architectural disciplinary practices. Operationalizing this notion results in a single ‘guard’ (or nurse/doctor in health care) who is able to watch dozens of people simultaneously because of the physical organization of the environment. The ASyMS© system extends this potential, allowing almost limitless numbers of patients to be under the gaze of one professional and offering a mechanism to observe and report on symptomatology. It could be viewed as a ‘perfect disciplinary apparatus’ which allows a single observer to survey all people constantly (Rabinow 1991, p. 191).

Medical staff, with pagers and passwords to data servers, have access to information about a patient’s symptoms and wellbeing. However, unlike prisoners in the panopticon, the patient also gains knowledge about their own health status, and is able to keep track of their own symptoms and side-effects and gain knowledge to address worrying toxicities; perhaps more importantly, they can opt out of the surveillance – unlike prisoners – thus rendering the power of the professional obsolete.

The study

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Implications for practice and/or policy
  6. Introduction
  7. Background
  8. The study
  9. Findings
  10. Discussion
  11. Conclusion
  12. Funding
  13. Author contributions
  14. References

Aim

The aim of the study was to identify the utility of a hand-held side-effect monitoring system for people receiving chemotherapy in the home care setting.

Design

In 2006, a pre- and post-test, mixed methods study design was used to assess the perceptions of people who used ASyMS© to report their symptoms during four courses of chemotherapy (Kearney et al. 2006). People affected by cancer contributed via advisory groups, providing feedback on the system and study methods.

ASyMS© was an addition rather than a replacement of the usual clinical care. Thus, in addition to the self-care information and monitoring provided by ASyMS©, patients were advised to follow standard protocols and guidance for reporting symptoms. As with usual care, they were in control of what symptoms they chose to report to staff, although the ASyMS© system could be considered a way of standardizing real-time feedback on symptoms.

Participants

Fifty-six patients having treatment for breast, lung or colorectal cancer at seven sites throughout the UK participated in the study. Patients were eligible to participate if they fulfilled the following criteria: having a diagnosis of breast, lung or colorectal cancer; commencing out-patient chemotherapy treatment (defined as those patients starting a new chemotherapy regime irrespective of stage of disease or line of treatment); aged 18 years or over; able to give written informed consent; able to read and write English and deemed by members of the clinical team to be physically and psychologically fit to participate. Patients were excluded if they did not meet these criteria or did not agree to give access to their case-notes. Patients were recruited to the study by the healthcare team involved in the study at seven recruitment centres.

To explore patients’ experiences of using ASyMS©, semi-structured interviews were performed at the end of the study with 12 patients who had received the intervention. All 12 transcripts were considered in the secondary analysis of the data reported in this study.

Data collection

Patients’ perceptions of ASyMS© were assessed before the start of the study using semi-structured perception questionnaires and post-study using semi-structured perception questionnaires and in-depth interviews (Kearney et al. 2003).

In the interviews, participants were asked to expand on their experiences of using ASyMS©, including the training they had received and their familiarization with the handset. They were asked about the alerting facility of the system, with questions such as ‘How do you feel about the nurses at the hospital being alerted about your symptoms?’ and ‘How did it make you feel when the nurses contacted you?’ Patients were also asked about the additional handset features, such as the self-care advice, general cancer information and potential development and use of the system in the future.

Ethical considerations

The study was approved by the appropriate ethics committee. Participants were given an information sheet and 24 hours to consider their participation. Participants were assured of anonymity and confidentiality and that the study did not replace routine clinical care, and written consent was obtained.

Data analysis

Details of the thematic analysis of the data have been reported elsewhere (Maguire et al. 2008, McCann et al. in press). A secondary analysis of the interview data is presented in this paper. As a departure from thematic and content analysis, the analysis was theoretically informed. Ideas applied in anthropology were used to help to separate out the differing claims that can be made from this kind of analysis, compared with traditional thematic analyses.

The distinction between reporting concerns directly expressed by participants (an emic approach which results in thematic type analysis), and attending to the concerns of theorists (an etic approach, such as presented here) is valuable. Thus, etic approaches create space for examining the data in the light of beliefs and values which are prioritized by the researcher (Headland et al. 1990). In other studies, we have focused on the concerns of participants themselves (the emic approach) have been published elsewhere (Maguire et al. 2008, McCann et al. in press).

In this study, we adopted a Foucauldian focus on surveillance and power (Foucault 1977, 1993). The rationale for this approach stemmed from an identification of key themes and ideas expressed by participants and by patient advisors. One advisor to the study (a patient with cancer) indicated that ASyMS© opens up new ways of having agency in communicating with healthcare professionals:

I’ve never been able to speak about how I feel, but I’ve been able to write it down. (Patient from research advisory group)

The new mode of communication is suggested to have an important function in re-framing the patient’s role in health care. Thus, the system allowed the patient to present themselves as agentic in representing and communicating the illness experience in a way that was understood as empowering. Respondents commonly expressed the idea that the system enabled them to feel that they had increased access to healthcare professionals, but without having to contact them face-to-face through formal channels. As one patient advisor (not a research respondent) reported, it felt as if healthcare professionals were on hand:

I felt that you had a doctor in the house.

To the research team, these statements and the raw data from interviews indicated a rich vein for investigating the role of surveillance in cancer care.

As with Brownlie and Howison (2006), we argue that ‘secondary analysis was appropriate in this case because these themes were evident yet under-developed in the original research and pressures on practitioners’ time make this a difficult population to gain access to’ (p. 434). The analysis presented here is supplementary because it is a ‘more in-depth investigation of an emergent issue or aspect of the data which was not considered or fully addressed in the primary study’ (Heaton 2004, p. 38). Key ideas of power and surveillance were identified and examined in the data, and then explored through reference to Foucault’s writing on these topics (Foucault 1977, 1979, 1993/1973). Iterative cycles moving between the research data and Foucault’s theories informed the development of the analysis presented below.

Rigour

The perception questionnaires had been successfully used in previous feasibility studies (Kearney et al. 2003). Interview data was analysed from a Foucauldian perspective by the lead author and discussed and debated within the research team until consensus was reached. The research team comprises two psychologists, a sociologist and two nurses. The psychologists and sociologist have all studied and/or taught Foucault’s theories and are familiar with his writing.

Findings

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Implications for practice and/or policy
  6. Introduction
  7. Background
  8. The study
  9. Findings
  10. Discussion
  11. Conclusion
  12. Funding
  13. Author contributions
  14. References

Participants who formed the sub-set of 12 people contributing to interviews were: two men, 10 women. Three patients had colorectal cancer, and nine had breast cancer. The age range was 38–66 years, with a mean of 50·58.

Reports from users of e-health

Interviewees felt that the system opened further lines of communication and allowed for a greater volume of communication. One indicated when this was likely to be particularly salient:

It would have been handy and especially at the weekends where there weren’t any people, em, you know, the Macmillan suite (specialist unit) was closed at the weekends […] it just would have been handy to have been able if you were worried about something particular, a particular symptom…. (Patient 7)

Thus, far from being at the mercy of the medical gaze, patients felt that the symptom monitoring system gave them easier access to cancer specialists. The notion of easy access subverts the typical understanding of medical surveillance, meaning that it is the clinician who is responsive to the patient’s reports and needs at any given time. This disturbance of the usual dynamic suggests that the use of technology may be an important tool in challenging traditional hierarchical models of health care which may marginalize patients, thereby contributing to the promotion of a patient-driven model of care.

Experiences of surveillance

Interviewees were asked for feedback on how they felt when staff got in touch as a consequence of worrying symptoms that had been reported using the system. Overwhelmingly, patients felt this was extremely useful and not troubling:

Researcher: And when the nurses contacted you how, how did you feel about that?

Patient 7: I’m happy with that, yeah, there weren’t any problem. I mean, they were either checking something, checking I was alright or, or whatever, you know, there wasn’t a, no problem at all.

Another interviewee offered this reflection:

Patient 8: Wasn’t a problem from my point of view, but in fact 1 day I’d come back from somewhere, there was a message and I was, you know, I was feeling absolutely fine, but obviously because you don’t want to waste anybody’s time but…

Researcher: Was that intrusive?

Patient 8: No, it was just a message, I mean, and from our family point of view, we’re very open. So it wasn’t as though it was a secretive thing, you know, so it wasn’t a problem.

Researcher: And how do you feel about the nurses at the hospital being alerted about your symptoms?

Patient 8: I think it was, it was helpful because it’s all a new experience and it can be quite frightening. So certainly, you know, I had quick action whenever there was a problem.

Despite the overarching message that nursing staff phone calls were motivated by ‘checking’, this notion was not problematized by interviewees. The idea that it might be intrusive was probed in interviews and, as the above quotation clearly demonstrates, was not understood as a form of oppression, but rather was interpreted as a liberatory mechanism, freeing them of the worry of having to take action themselves.

A further patient summarized her thoughts on symptom surveillance as reassuring:

Patient 9: I think that the whole thing, if I could sum up, just the whole experience is reassurance…because, you know, it’s a big thing and, and the mind plays tricks, and left in the house on my own and all the rest of it for a while. But no, they were very, very good and, eh, and the fact that they were able to respond so quickly, as I say, was, was really great.

Thus, being the object and subject of the medical gaze through self-reported symptoms being followed-up by healthcare professionals was not expressed as problematic, but as ‘good’ and ‘great’. Although Foucault discusses the potential for the medical gaze to separate the physical illness from the person (Foucault 1993), this idea was not borne out by our interviewees.

Docile bodies or agentic patients

Participants reflected on their agency in health care. Speaking about how professionals were able to monitor her symptoms remotely and call if her reports were of clinical concern (and elicited an amber or red alert), one patient said:

You know, and I think that’s quite common with patients, where they won’t phone the doctor, they won’t [phone] the nurse, you know, because they’re too busy. Em, so I would have said that’s quite reassuring, it was like being monitored in a kind of, very kind of non-invasive way, you know, and you didn’t feel that you were bothering anybody. (Patient 11)

Another respondent offered thoughts about agency and control, comparing her non-hesitant approach to hypothesized others’ responses, who might require a proactive approach from staff:

That decision’s taken away from you. I mean, from my point of view, if I was at all worried I really wouldn’t have hesitated in actually picking up the phone. But not everybody’s like that, so I think that’s a good thing. (Patient 12)

The ‘decision’ referred to in this quotation was calling the hospital when feeling particularly unwell. The speaker marked out the need for the system for other patients who might hesitate in contacting the hospital.

The virtual presence of a healthcare professional relieved patients of the responsibility of deciding whether symptoms warranted attention. In this way Foucault’s notion of the docile body is called forth, and the technology acts as a tool whereby the patient’s agency is reduced and they take on a more passive role. It is possible that such medical surveillance may be internalized by the patient, which in turn may lead to them failing to take a more assertive approach.

Another interviewee’s ideas suggested that the system, and professionals’ responses, sometimes placed the onus on the patient to take the lead:

You always felt that somebody would, was, was going to be contacting you if you were it [ill], you know, if you had worrying symptoms, but that in actual fact didn’t quite happen in as much that, that the only time I had a, a whole group of symptoms and I was particularly unwell…they just advised me to phone the hospital, which was fine. It’s not that anybody was phoning you, you know, they weren’t automatically phoning me. I, I phoned the hospital, so I suppose it was just all very reassuring…you felt you were kind of being monitored more closely, rather than, you know, that 3 and 4 weeks apart, just coming up for your treatment. (Patient 1)

This person picked out several core features of the system and, in doing so, positioned herself in relation to the power dynamics of health care. She noted that in response to a cluster of symptoms she is prompted to phone the hospital, which comes as a surprise since she had been expecting to receive health professional phone calls. Thus, her account presented her as being uncertain about the locus of responsibility for following up worrying symptoms. The notion that she ‘always felt that somebody would…be contacting you’ flags up a concern that contact from the hospital could be experienced as too much. However, the outcome was her surprise that responsibility for the call lies with her. The system, however, assists with decision-making about whether the presented symptoms necessitate follow-up.

The notion of ‘monitoring’ in the above account directly invokes ideas of surveillance. However, it is presented not as daunting/unwarranted, but as reassuring. The frequency of contact between patient and hospital using this technology is twice daily rather than every 3 or 4 weeks, and is interpreted as a positive step for feeling looked after between treatments (when side-effects are most likely to be apparent). Thus, far from being experienced as an enactment of the docile body, patients embraced the new relationship they were developing with their own agency in their health care.

The medical gaze reconsidered

Participants gave the distinct impression that the new system subverted the traditional power hierarchies of medicine, placing the patient as more central and having control/agency in their care. Indeed, rather than being forcefully and negatively subjected to the medical gaze, these systems act as welcomed enforcers of the medical gaze, mandating healthcare professionals to attend to patients’ needs.

The constant gaze to which patients feel themselves subjected is experienced as a positive and embracing component of care. Thus, the medical gaze, which may or may not be regularly assessing symptoms, is experienced as an apparatus that facilitates constant monitoring of wellbeing rather than an invasive mechanism of control. This creates a new sense of agency where patients report symptoms in the knowledge that these will be acted upon by healthcare professionals if necessary. Thus, power is renegotiated through the communication of symptoms using new technologies. The notion that healthcare professionals ‘hold’ power in encounters therefore needs to be questioned, and essentially re-positions the patient as holding power and directing practitioners to attend to them as required.

The virtual examination performed through the newly routinized electronic world of the system’s symptom questionnaire offers a way of categorizing and measuring against a normative marker of symptoms and side-effects. Yet, the interviewees did not experience this as an objectification of themselves of their cancer, but as affirmation of their symptom experience.

Discussion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Implications for practice and/or policy
  6. Introduction
  7. Background
  8. The study
  9. Findings
  10. Discussion
  11. Conclusion
  12. Funding
  13. Author contributions
  14. References

The limitation of this study was that interviews were conducted only at the end of the course of chemotherapy. Consequently, the views expressed by participants represent later reflections on the technology rather than thoughts during the early use of it. The theoretical analysis precludes us from making claims about people’s motivations and intents in presenting views of the system, although participants may have spoken positively about the system as a by-product of being pleased that they did not feel compelled to travel to (often distant) hospital clinics to report worrying symptoms.

ASyMS© was developed to enable monitoring of people receiving chemotherapy in remote and rural communities. The policy change (Scottish Executive 2005) to treating people in their own homes and communities knits with the Foucauldian critique of hospitals as an ‘artificial locus’ and the notion of enabling patients to remain in:

the familiar surroundings of his (sic) home and family. (Foucault 1993, p. 18).

It is recognized that remote monitoring may not always be clinically appropriate; however, it could be argued that the re-location of cancer care into a person’s home and community contributes to the destruction of the dividing practices which Foucault argues are typically invoked to marginalize and exclude people (Foucault 1977, 1993/1973).

This study provides evidence and reassurance that the technological innovations observed in cancer care and other domains of nursing practice (e.g. dementia care, Margot-Cattin & Nygård 2006) are welcomed by patients. The ability to extend modes of communication, particularly where patients live at considerable distance from treatment centres, is considerable in addressing Roine et al's (2001) call for care which transcends geographical boundaries. Similarly, the application of Foucault’s theory to examine critically the accounts of people using healthcare technologies provides encouraging evidence that the communication and subsequent assessment of symptoms can be appropriately monitored without concern that this will be experienced as infringing patient’s privacy (Cleeland et al. 1986;Cleeland et al. 1994).

Conclusion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Implications for practice and/or policy
  6. Introduction
  7. Background
  8. The study
  9. Findings
  10. Discussion
  11. Conclusion
  12. Funding
  13. Author contributions
  14. References

Foucault’s theories on power and surveillance offer a useful critical view of the new technologization of health care. There is a need to question the straightforward assumption that being a patient with cancer and being under surveillance are uncritically negative. However, it is clear that the system is not a problem for people using it, and that the technologies of power are welcomed as aids in promoting patient empowerment.

As healthcare technologies are being rolled out internationally, this Foucauldian understanding of health care, power and surveillance has the potential to inform policy and practice developments in cancer care and beyond. Different cultural contexts will undoubtedly lead to shifts in attitudes and views of the position of surveillance in health care and should be explored with patients and healthcare professionals accordingly.

Future researchers in the domain of technologized health care could specifically look at power and shifting views of the medical gaze to examine further the dynamics which have been described and illustrated in this study.

Author contributions

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Implications for practice and/or policy
  6. Introduction
  7. Background
  8. The study
  9. Findings
  10. Discussion
  11. Conclusion
  12. Funding
  13. Author contributions
  14. References

RM & NK were responsible for the study conception and design. RM & LM performed the data collection. LF & NI performed the data analysis. LF, RM & LM were responsible for the drafting of the manuscript. LF & NI made critical revisions to the paper for important intellectual content. NK obtained funding. LM provided administrative, technical or material support. LF & NK supervised the study.

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  2. Abstract
  3. What is already known about this topic
  4. What this paper adds
  5. Implications for practice and/or policy
  6. Introduction
  7. Background
  8. The study
  9. Findings
  10. Discussion
  11. Conclusion
  12. Funding
  13. Author contributions
  14. References
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