Cyber nursing: a conceptual framework

Environments – virtual communities and virtual self-care

Places where humans interact have, until a few decades ago, been geographically restricted. However, with developments in technology, the Internet has solved such boundaries. In our previous studies, we have described how individuals communicate in relation to health related issues in virtual communities. Moreover, in one study (Salzmann-Erikson and Eriksson, 2012) we stressed something that also goes beyond a communication style and a use of technology – virtual environments have the capacity to unite people as ‘opportunities to find people with similar interests, values and goals have expanded’ (p. 9). This is extraordinarily important, since many individuals suffer from health related issues that lie outside of societal norms. For example, psychiatric illnesses, sexual deviations, living with HIV, poverty and obesity are regarded as taboo and ‘deviant’.

We emphasise that the evaporation of physical boundaries created by digital environments will bring individuals into contact with others who are in the same situation as themselves in a ‘safe manner’. Hence, we stress that digitalised environments offer new possibilities and can provide access to a more complete life among individuals. In a study of fathers’ sharing of parental support (Salzmann-Erikson and Eriksson, 2013), we discussed how fathers may become aware of a gendered system:

There is a common notion that many of men’s day-to-day activities, in both public and private settings, are not regarded as gendered at all since men are often unaware of their privileged positions in what can be considered as a patriarchal gender order. However, the posters gradually seem to realise that ‘being a father’ involves taking part in a wider gendered system. (p. 387)

We consider that such awakening, originating from interacting in digital environments, may contribute to a wider awareness of, for example, gendered systems, and that this forces individuals to a higher level of participation in society (cf. Eriksson et al., 2014b). In post-industrial society, which enables individuals to live their life to a large extent in online environments, the human geography of the home environment has been repositioned into digitalised arenas (cf. Eriksson et al., 2014a). However, the need and longing for increased well-being has not ceased. Rather, the explorative access to information and connected life styles prompt individuals to take part in the digitalised environment more intensively. Hence, we argue that this rearrangement of health geography has implications for individuals, as it intersects and affects the possibilities of the virtual shared values of health (Salzmann-Erikson and Eriksson, 2015b).

Within this definition of self-care, self-care practices can be recognised throughout the lifespan of a person as a human regulatory function in everyday life that is aimed at maintaining health and avoiding illness and that also includes virtual self-care activities (cf. Orem, 1995). This virtual opportunity reinforces the importance of recognising that ‘the self’ can act in this virtual environment simultaneously as both agent and object and that the processes of shifting between being agents and objects of action are closely intertwined. Therefore, we argue that Orem's self-care theory can be a valuable tool for understanding the self-care activities that are available over the Internet, and that ‘virtual self-care’ can be used in this context as a common ground for contemporary nursing theories and thereby move Orem’s thinking into the virtual territory (1995).

Health interactions – torrenting

The interactions and processes that take place in virtual arenas are complex. This complexity in interaction originates from the idea that the interactions lack predictability in the occurrence of events in the systems, as they have no hierarchical order. These tenets were previously detected in our studies of virtual self-care in online environments. We conceptualised the term torrenting (Salzmann-Erikson and Eriksson, 2011) from studying how women support each other in a non-linear way in a forum for breast augmentation. Information was provided through interactions without any superior structure, apart from the flow or swarm behaviour of exchanging information. In addition, we stress that torrenting is a tenet of self-care activity, although it also has considerable value for observers. Hence, we emphasise that it is just as important to understand the mechanism behind torrenting. Complex contagion explains this mechanism. In contrast to simple contagion,

the intermittent nature and irregularity of the torrenting activity means that a posted question generates answers from other posters along different timelines according to their own experience of the phenomenon in focus. (Eriksson and Salzmann-Erikson, 2013: p. 343)

The ability to gain information from contacting others in similar situations is a crucial and important possibility that motivates people to seek support on the Internet. One frequent way of providing virtual support in forums was by offering advice. Advice usually took the form of guiding fellow posters and participants who had earlier addressed the topic, acting as a source of expertise. Sometimes, excerpts from pamphlets and books were used to emphasise the advice given. References to research, literature and nurses’ or midwives’ statements were made when giving support to others (Salzmann-Erikson and Eriksson, 2011; Eriksson and Salzmann-Erikson, 2012). Practical advice about sleep, food, weight, social and physical development and activities were the most frequent topics. In the same way, posters in an Internet forum for breast augmentation also encouraged each other with sympathetic comments throughout the process. Prior to surgery, encouragement was manifested as applauding the engagement of new posters, and turned fear into something positive by presenting examples of their own experiences (Salzmann-Erikson and Eriksson, 2011).

We identify support as being a form of reciprocal sharing. Experience-based advice, the sharing of information and the promotion of good examples are the basis of sharing experiences in virtual support. We suggest that this type of social support on the Internet can be regarded as an imperative tool in gathering information and making sense of care-giving experiences. For example, in our studies of support for new fathers, we concluded that support works twofold. Through sharing, the fathers could connect with others who could benefit from their experience, but they also derived benefits from paying forwards, which helped the fathers to perceive their caring experience as something valuable and positioned them as skilled fathers within the forum (Eriksson and Salzmann-Erikson, 2012; Salzmann-Erikson and Eriksson, 2013). This was manifested as posters supporting others by sharing excerpts from pamphlets and books to support their own expertise in the matter of caring. In this way, they developed the role of being advisors to other fathers in the forum and became ‘experts’. By using their own fatherhood as a model for others and sharing gained knowledge over a longer period, the fathers paid their experiences forward, following a ‘pay it forward’ principle. It is clear that the users of virtual self-care praise the opportunity to connect via cyberspace with others who share the same experience and situation, because it creates a social arena for personal manoeuvring and offers a crucial link to others. Like detectives, the posters used bits of information to construct a complete picture of their own self-care in relation to their problem (Salzmann-Erikson and Eriksson, 2011). Torrenting centred on this piecing together of information, as well as the posters’ own emotional reactions to their particular situations.

Human performativity – co-existing experts

Distinctive types of experts emerge in the forums. In our studies of expert profiles, we have detected (1) those that build their expertise by creating a presence in the forum based on lengthy and frequent postings, (2) those who build a presence through reciprocal exchanges with individual posters with questions or concerns and (3) those who build expertise around a ‘lifelong learning’ perspective, based on logic and reason (Eriksson and Salzmann-Erikson, 2013). Throughout the flow of interactivity online, one type of textual performativity is that carried out by what we termed ‘the keyboard cowboy’. It is characterised by the volumes of text that are being produced in a non-Hippocratic style and writing about ‘how it should be’ and ‘ought to be’ in his or her opinion. The cowboys have a dense presence in the forums, and consequently develop relationships with a community of people, who in turn often back their opinions. As a consequence, the cowboy has a wide range of social connections, and also uses the forum as a place for chatting publicly with his or her closest ‘forum friends’.

A second type of performativity as an expert in the health forums is that carried out by what we have labelled as the ‘cyber aid’. The aid is an ‘active listener’ in the forum and represents a humble approach; he or she spreads warmth and creates a positive atmosphere. The expected activity is to electronically sooth the fellow poster and ease frustrations, worries and fright. The cyber aid’s raison d’etre is achieved through reciprocal postings whereby the aids provide an endorsement in an ‘I–You’ relationship.

The third type of performativity is that carried out by those experts who spread information and knowledge that is explicitly based on others’ knowledge and who convert this into their own expertise. We have labelled such persons as “traders in health-interests”. The trader uses sources of information that originate from encounters with formal health care professionals, for example nurses, physicians, formal websites and sometimes magazines. The trader also uses second-hand experience from encounters with sources of formal expertise to support his/her arguments, by referring to sources outside the forum. The trader seems to regard the forum as an opportunity to link ‘theory’ and ‘practice’. Since the overall approach of the trader is to teach, a pedagogic approach is presented in the forum, which is problem oriented and based on logical reasoning (Eriksson and Salzmann-Erikson, 2013).

It is important to understand the diverse individual performances of those who participate in health forums as they form complex structures and processes through their interaction and interplay. This suggests that experts not only co-exist in the forums but, more importantly, that they reinforce each other’s positions. This effect is of great importance. Alongside one another, the posts of the three types of experts that we identify constitute a whole, who are also called ‘seeders’, for those seeking the forum for advice and support.

Users are provided with strong opinions and advice, support and Socratic reasoning, and a problem-oriented approach. We stress that the performativity of these experts is not static and also users are able to, at times, be ‘leechers’, that is, persons who acquire information. In the complexity of the many interactions within the posters’ performativity, we addressed information exchanging as swarm behaviour, in which some posters benefit from others’ information in an arbitrary order. When viewing the three at a distance, new formations can be seen:

there is a mutual dependency as the one coexists upon each others individual existence – that is; the seeder would not be an expert without a leecher who acquiesce the information and being the underdog who is taking part of discussion, or being advised. (Eriksson and Salzmann-Erikson, 2012: 344)