Perspective Chapter: Ubuntu Model of Health Care – Re-Envisioning Nursing Practice in the Digital Era

Abstract

Ubuntu is an African philosophy that emphasizes the importance of care, concern, and interconnectedness between people. During the period of the COVID-19 pandemic, nurse practitioners and nurse educators were forced to rely on digital technology, but many faced challenges due to a lack of resources and skills. To adapt to global changes, nurses need to embrace digital transformation and be involved in the design and implementation of digital technology. Unfortunately, nurses’ voices are often unheard in this process. The Ubuntu philosophy can offer valuable insights, reflecting the African continent’s ethos and social wisdom, to promote digital inclusion. In this chapter, we will delve into the significance of an African voice in digital governance through the lens of the Ubuntu community model of nursing.

1. Introduction

The rapid integration of digital technology into professions and personal lives has also influenced the role of nursing, which is to provide compassionate and humanistic care to patients [1]. The COVID-19 pandemic has presented unprecedented challenges for healthcare workers, especially those in nursing. However, it has also created opportunities for integrating digital technology in healthcare and education [2]. To adapt to new ways of providing services, healthcare professionals and educators have turned to digital tools such as telehealth, online communication platforms like Zoom and Google Meet, and even artificial intelligence. These digital methods of care have expanded and improved access to care for many patients, and reduced per capita health costs [3].

Healthcare professionals have successfully embraced the opportunities presented by the digital age, using technology to enhance their practices and elevate the quality of patient care [4]. With cutting-edge technology, healthcare professionals can now use electronic medical records, and diagnose and treat patients in novel ways, by using diagnostic tools such as mobile ultrasound machines and 3D printing. Hospitals have also introduced robots to serve as supplemental healthcare workers and assist with other tasks that require less human intervention [5]. These tools are used to identify patient needs, diagnose, and treat patients early, prevent medication errors, and improve compliance with practice guidelines thereby improving patient safety [4, 6]. In addition, simulation methods are used in nursing education to teach student nurses [7].

However, innovations in digital technology have posed ethical challenges in many fields including nursing practice. Some scholars argue that ethical principles such as compassion and caring which are the core of nursing and healthcare practice cannot be replaced by robots and machines with automated decision-making systems [5]. Nurses provide compassionate care and uphold ethical values such as respect, beneficence, justice, and non-maleficence. Compassion is a crucial element of the healing process, as it directly impacts the quality of healthcare outcomes. Nursing with compassion entails placing the patients at the core of care. The same sentiments are expressed in the Chinese culture in Confucianism. Based on Confucian approaches, all people are social beings and relational. The core beliefs are respect for elders, harmony between individuals, justice, loyalty to family and friends, and filial piety which is viewed as respect for one’s parents [8]. However, nursing is not limited to this aspect; it combines both an art and a science [9].

Robots may not be able to provide the relational ways, humanization, and values expected in nurse-patient relationships. Similarly, the use of simulation techniques in nursing education has been questioned as nursing students are not given opportunities to practice on real patients. However, Samani et al. [10], observed that cultural values can influence the development of robotics and that robotics can create its values and cultures. Furthermore, Mhlambi [5] has also proposed using the values of the African philosophy of Ubuntu to create a more relational framework for governing artificial intelligence. They propose that robotics should focus on enabling virtues and the social and relational aspects of robots. While embracing technology in healthcare, it is crucial to be mindful of the caring aspects. The chapter proposes the application of the African philosophy of Ubuntu as a foundation of caring and the basis for the Ubuntu model of healthcare in the digital era.

2. Lessons from the COVID-19 pandemic that should make us re-envision healthcare and nursing practice

At the peak of the COVID-19 pandemic, the global health workforce was called upon to lean on technology more than ever to support their practice. The pandemic highlighted the need for telemedicine or telehealth, the provision of health services through telephone, email, and videoconferencing. It is a health-related service which relies on telecommunicating and electronic information technologies to facilitate consultation, screening, health education, and information-sharing [11]. Telemedicine became necessary for triaging and screening for COVID-19 symptoms, deployment of services, collaboration between the multidisciplinary team, and continuation of care provision while reducing the in-patient burden [12]. It also helped to promote social distance between the healthcare providers and their patients. However, many struggled for a timely and coordinated telehealth response due to the lack of skills [13]. Since then, digital health has been transforming healthcare provision and is strongly recommended by the World Health Organization to improve healthcare and nursing practice [14].

In addition, the global pandemic brought a silver lining by shining a spotlight on the exceptional work done by nurses worldwide [15]. People are now more aware of the advanced clinical skills that nurses possess, the complexity of their job, their unwavering commitment to patient care, and the critical role they play in providing comfort and compassion to patients in their last moments [16]. Despite the challenges such as workload and stress [17], the nurses felt like superheroes due to the responsibilities that they shouldered during the pandemic [18]. It is expected that the nurses’ previous experiences in handling difficult situations during the pandemic will make them more confident in dealing with stressful situations [17].

The pandemic must be a catalyst for fundamental and systemic change in preparedness for future global outbreaks [19]. Nurses are at the frontline of healthcare, representing more than 59% of the world’s healthcare workforce. As such, the effectiveness of health service delivery is influenced by the state of the nursing profession [16]. They have first-hand knowledge of the challenges and barriers to health [12]. They play a central role in efforts to achieve universal health coverage and the global Sustainable Development Goals (SDGs). Some of the challenges that were exposed by the pandemic can be addressed by investing in nursing education and enabling nurses to be empowered in digital technology and artificial intelligence. There is a need to provide ICT training, IT support, computer accessibility, and social media access to equip nurses with digital technology [20].

Nurses must also consider the pandemic as an opportunity to reflect, learn, and grow [16]. Renewed awareness of digital technology offers an impetus for change that nurses should embrace. Nurses must radically reframe their relationship with digital technology to achieve universal health coverage by 2030. They also need to learn to engage relevant stakeholders, provide leadership, and champion such initiatives. Unfortunately, the nurses’ voices are absent in the design and implementation of digital technology although they constitute most of the healthcare workforce. Promoting the nurses’ digital literacy and involvement has the potential to improve health outcomes. A digitally enabled nursing profession will also attract the youth into the profession. Ultimately, this will help to curb the global shortage of nurses. On the other hand, failure to involve nurses will lead to a lack of trust in the technology, reluctance towards its use, and pose a risk to cyber security issues [12]. Lastly, health professionals including nurses are challenged to navigate the new models of care in this digital era.

3. Ubuntu in nursing

Ubuntu is a term that is expressed in different languages but means the same thing in African countries. For example, it is called gimuntu in Angola, muthu in Botswana, umunthu in Malawi and bantu in Rwanda [21, 22]. In South Africa, Ubuntu is a Nguni word that is expressed in the idiom, muthu ndi muthu nga vhathu and loosely translated as I am because you are [23]. Similarly, in Malawi, the relational aspect of Ubuntu is expressed in the saying, a loner is a beast, those in the company of each other are humans [24]. The black African people believe Ubuntu is a collection of values that make a human being authentic. It emphasizes interdependence and interconnectedness among people such that a person is perceived as authentic when they belong to a larger and more significant relational, communal, societal, environmental, and spiritual world [21]. Ubuntu is also perceived as a caring ethic and a core of nursing as it promotes care, respect, concern, and engagement for one another [22, 23].

The Ubuntu model of healthcare is a new approach to nursing practice that seeks to re-envision the role of nurses in the digital era. It aims to incorporate technology to enhance the delivery of healthcare services while maintaining a human-centered approach to care [25]. This is consistent with Coeckelberg [26] recommendation for an Ubuntu social robot that will be able to accommodate the values of Africans as the current social robots are based on Western individualism. However, Mhlambi [5] argues that automated decision-making machines and robotics cannot replace personhood. Nurses are a connection point between innovations and patients [12] therefore they have a critical role in collaborating with engineers, researchers, and technologists to ensure that the human part and the cultural aspects are embedded in shaping future designs of social robotics.

As nurses, we should embrace the renewed awareness of digital technology and view it as an impetus for positive change. The pandemic has presented us with an opportunity to make fundamental and systemic changes in our preparedness for future pandemics, and we should seize it with enthusiasm and determination. Nurses have a critical role in achieving universal health coverage by 2030. To achieve this ambitious goal, we must revolutionize our relationship with digital technology [15]. Nurses are expected to embrace Ubuntu and lead the way towards a healthier, and more equitable future. We must do so within the context of our Ubuntu caring ethics, which emphasizes the interconnectedness of all individuals and the importance of treating everyone with care, respect, and engagement. By adopting the spirit of Ubuntu, nurses can better engage, empower, enable, and emancipate the patients and clients they serve, leading to better healthcare outcomes for all [22].

4. The need for digitalization

According to the strategic directions for nursing and midwifery 2021–2025 [19], nurses and midwives must be trained to acquire cross-cutting competencies in digital technology. The statement advocates for nurses to embrace digital technology. However, it acknowledges that digital transformation does not only need technical advancement but also a change of attitude and adaptation among the health workforces. Successful implementation of digital technologies requires understanding of the nursing workforce as demographic variables such as gender, age, voluntariness, use, and experience may influence their acceptance and utilization of digital tools [27]. Women are more likely than men to own a mobile phone, but they are 20% less likely to use it to access the internet. Given that more than 90% of nurses are women, the digital gender gap poses serious challenges for this sector [27]. It is time for us to act and address this issue by providing access to resources and training that empower women in the nursing community to improve their digital skills. This initiative is especially crucial in low- and middle-income countries with scarce resources, and the gender digital divide is even more pronounced. There is a need to close this gap and ensure that every woman in the nursing field can access digital tools and improve their skills.

5. Ubuntu values and digital inclusion

Digital inclusion is defined as “equitable, meaningful, and safe access to use, lead, and design of digital technologies, services, and associated opportunities for everyone, everywhere” [28]. It is a notion that everyone, regardless of their background, should have access to technology and the internet. According to Amugongo [29], the principles of Ubuntu that can be aligned with digital technology and AI are fairness, community good, safeguarding, humanity, and respect. The Ubuntu principles must be infused in the design deployment and the use of digital technologies. Furthermore, we propose digital technology and digital inclusion should be aligned with Ubuntu principles that form part of the Ubuntu model of nursing (see Figure 1). The principles that can be applied include collectivism and solidarity, participatory decision-making, a sense of belonging, and consensus [30].

Figure 1.

Ubuntu model of nursing.

6. Ubuntu community model of nursing

Ubuntu community model of nursing proposes a framework that acknowledges that a person exists in an environment and belongs to a community. The environment is composed of earth, air, water, animal, and plant. As reflected in Figure 1, the community has values which include respect, role-modeling, responsibility among others. In addition, there are principles namely collectivism, solidarity, and communitarianism; collaboration; participatory decision-making; sense of belonging; sharing of responsibilities and challenges; consensus; communication and dialog. When these principles are applied in healthcare, the consumers of care feel engaged, enabled, empowered, and emancipated. Therefore, we propose that the principles of the model be applied in the integration of digital technology in health practice.

6.1 Collectivism, solidarity, and communitarianism

The principle of collectivism, solidarity and communitarianism emphasize that communities must work together and be there for each other [31]. The common good for all becomes a priority rather than individualism. Digital inclusion prioritizes equity, access, and community at its core [29]. The essence of Ubuntu is the belief that the community is more important than the individual. Ubuntu enables people to think and act collaboratively and communally. It is important to ensure that digitalization embraces the principle of communalism [32]. This principle is commensurate with the principle of utilitarianism which is used in western bioethics. Utilitarianism emphasizes that ethical decisions are made based on moral values which allow most community members to benefit [33]. In this case, if nurses embrace digital transformation and allow digital inclusion in their scope of practice, quality patient care will be provided as digitalization will ease the load on nurses through electronic records, robotics, and telehealth. These will enable them to have enough time to focus on nursing duties only and render quality patient care. Patients will also benefit from the digitalization.

6.2 Collaboration

Collaboration involves working together for a common goal. It is important that everyone, including nurses, possesses the necessary skills and knowledge to participate fully in our digital society. We need to acknowledge and appreciate the diversity of our communities, including differences in language, culture, and ability. Therefore, it is essential to design technologies and digital experiences that are accessible and inclusive for all, ensuring that everyone has a voice and a seat at the table from the design phase of the automated machines. For instance, an AI tool that was created to detect skin cancer was trained on a dataset of images primarily from fair-skinned people. As a result, the tool may fail to provide an accurate diagnosis for individuals with dark skin [29]. As caregivers, we must prioritize human interaction and care above all else. By neglecting this responsibility, we risk damaging the trust that nurses place in technology, which can lead to reluctance towards its usage [12]. Let us make sure we always put the needs of patients and nurses first and utilize technology in a way that enhances their experience and outcomes.

The use of technology in the clinical workplace is becoming more prevalent. However, this widespread use can also create reluctance towards its usage. Additionally, as more medical professionals interact with each other online, there is a growing concern about the perpetuation of gender-based violence [12]. To mitigate this risk, it is essential to have safety features such as accountability settings, and spam and harassment filters to ensure a safe and secure online environment.

6.3 Participatory decision-making

Participatory decision-making is the ability to respect other human beings, their views, and opinions. Respect in Ubuntu is not one-sided but reciprocated. There is mutual respect as both parties respect each other [30]. Ubuntu’s philosophy emphasizes patient autonomy while at the same time recognizing the interconnectedness and interdependence between community members. Amugongo et al. [29] argue that the emphasis of Ubuntu on the needs of communities may compromise individual rights. Indeed, Ubuntu emphasizes communalism but at the same time guarantees every person’s rights and responsibility to be able to exercise moral obligation to think on behalf of others. Thus, while designing our digital machines we will have to understand the incorporation of cultural values. Coeckelberg et al. [26] suggested that cultural robotics be incorporated to ensure that the machines resemble the cultural values of the communities we serve. Participatory decision-making constitutes respect for everyone’s integrity, freedom of speech, and expression.

The Ubuntu philosophy emphasizes the ability to respect a person’s integrity and freedom of choice [22]. Respect in digitalization and AI will involve incorporation of the users views from the conception and design to utilization phase [29]. In the digitalization space respect entails involving people in decision-making from the inception of the project, the design of machines, and the utilization phase. The process will enable nurses to be receptive and accept changes. They will get an opportunity to give inputs to ensure that the caring aspects are included. Van Norren [34] posits that when a machine algorithm is programmed by Westerners there is usually a gap as the inputs of Africans who are using the machines are often not incorporated. The principle of Ubuntu promotes values such as reciprocity, benevolence, and humility.

Respect also entails freedom of choice and the ability to make decisions in health care issues [23]. People need full information about the advantages and disadvantages of the procedures that are undertaken in hospitals and clinics. With the introduction of AI, there are a lot of new machines and medical tools introduced for assessment and diagnosis. The issue of informed consent becomes paramount to providing people with their inherent dignity [29]. However, the challenge of informed consent is individual informed consent versus communal informed consent. With the introduction of other procedures and AI tools that affect communities, there may be challenges concerning informed consent related to AI models that affect the whole community. For example, there is a proliferation of websites that can access people’s data and publish health information and education without obtaining informed consent or following proper channels [29]. Social media can also be a challenge where photos of patients can be posted to platforms such as Facebook without the knowledge of the hospital authorities and patients themselves. Policies such as the Information and Data Protection Acts must be available to protect people from harm. Vulnerable users must be protected from risks and harm that can be inflicted by technology [35].

6.4 Sense of belonging, sharing of responsibilities and challenges

The sense of belonging is also another principle of Ubuntu which refers to sharing of opportunities, responsibilities, and challenges. In African communities, people learn to share resources and basic needs such as housing and food at very tender ages. Thus, when educational opportunities present themselves, people prefer to share information to empower each other with knowledge and skills [22]. Similarly, it will be paramount to embrace the principles of Ubuntu in digital technology to facilitate learning among nurses and other health professionals. Nurses must learn more about digital technology to acquire skills.

There is a need for fairness in the distribution of resources, knowledge, and skills to ensure equity. This notion is supported by Amugongo et al. [29], who argue that the Ubuntu philosophy promotes fairness which ensures that there is equity and justice in the distribution of resources in digital technology and AI especially in low-income countries. The course of action taken in the decision-making regarding training and designing of digital machines must be fair and just [33].

There is an inequity of digital resources between developed and low-income countries. In addition, some of the nurses lack skills in digital technology. This can be attributed to a lack of resources and technophobia. The incorporation of Ubuntu in embracing technology can assist in addressing inequity as it promotes virtues such as mutual inclusivity, supporting each other, a sense of belonging, and obligations to each other. Factors such as gender and age may also have a bearing on inequity. Women may lag in adopting technology due to financial constraints [29]. Ubuntu is a justice theory that promotes fairness [33].

6.5 Consensus

One of the principles of Ubuntu is to resolve problems by seeking consensus to ensure that all members of the community are satisfied and happy with the decisions taken [30]. The involvement of healthcare practitioners and nurses in decision-making during the designing of the models will enable them to give inputs that will incorporate caring values. The designers of digital tools and models must involve all stakeholders and users of those technologies to get more inputs and buying in. Decision-making must be based on consensus.

6.6 Communication and dialog

In the African setting, communication is essential for informing communities about messages, and activities. The communication often takes place through dialog. Ubuntu-centered communication values online communities that are interactive and characterized by respectful communication, reciprocity, and mutual trust [36]. Through the lens of Ubuntu, the introduction of technology in health practice including nursing should be a negotiated activity that respects the values of proper communication and dialog with the communities, the consumers of healthcare and other relevant stakeholders. Similarly, the online communication platforms must incorporate the values of the communities.

7. Barriers to digital transformation in nursing

Nurses often view digital technologies as a hindrance to the intimate and empathetic relationships they build with their patients and their families. They perceive these technologies as a distraction from their hands-on caring role. This resistance to adopting digital approaches to healthcare is primarily due to the belief that it contradicts traditional nursing ideals, such as compassionate care. Nurses’ resistance to technology has been well documented. When digital tools such as computers were introduced, nurses resisted through avoidance, and criticism to the extent that some just refused to use them [27].

Resistance to change may be seen from all health care professionals due to lack of awareness regarding the benefits that new technology may bring to the organization. The cost of digital tools is often very high which makes access to the tools difficult. Resistance can also be from patients who are not willing to try new technology for fear of the unknown. Digitalization must be designed in a way that will benefit patients [37].

Processes that can inflict harm to clients, nurses themselves and the profession must be avoided at all costs. The use of technology can be addictive and harmful. It can lead to both physical and mental conditions such as depression and anxiety. In response, the World Health Organization has incorporated gaming disorder under the classification of disease [35]. With regards to harm to clients and the profession, there are many questions that we need to ask ourselves; do we see ubuntu on social media these days or do we see criticism, blame, shaming, defamation, abuse, hate speeches, negative comments, sexism, xenophobia, Afrophobia and so many other negative things? Additionally, nurse educators are facing challenges in incorporating ChatGPT (generative pre-trained transformer) into their teaching curriculum. Plagiarism is rife and difficult to control. Ultimately, this will negatively affect the competence of our newly qualified nurses.

8. Recommendations

There is a need for Ubuntu-based action guidelines principles for all AI stakeholders. African countries need individual, institutional, and national digital and AI governance capabilities at continental and global levels. Digital technology and AI machines and robots must reflect the African ethos and wisdom. Facilitation of deeper discussions and scientific research regarding access, cost, electronic resource use or wastage, is necessary to ensure proper guidance on the use of digital tools. Digitalization of nurse-patient relationships will also need to be thoroughly explored. We need to change our mindset and embrace Ubuntu even in our interactions through social platforms. Nurses must be vigilant and establish ethical committees that will ensure that the digital models designed through AI incorporate cultural and ethical values.

There is a need to take steps to address the challenges that were exposed by the pandemic through investing in nursing education and enabling nurses to be empowered in digital health. Change management is critical to ensure buy-in from nurses, administrators, and patients. Training and education of staff is critical to ensure that they are equipped with knowledge that will boost their self-esteem and confidence in the use of digital technology.

In addition, ethical frameworks that govern digital technology in health care must be in place in all countries to protect individuals and communities from the risks and harm that can be caused by digital technology. Formalizing a connection and aligning synergies between the whole of nursing and digital health will lead to improved technology and health outcomes. The African philosophy of Ubuntu can be applied as a foundation of caring and the basis for the Ubuntu model of healthcare in the digital era.

9. Conclusion

Digital technology is here to stay, it is our future. Ethical challenges such as lack of privacy, safety, security, fairness, transparency, accountability, and lack of promotion of cultural and human values have arisen in nursing practice due to innovations in digital technology. Digital competencies are still not well defined for the nursing profession or formally integrated into nursing education and practice. Nursing education must incorporate digital technology to equip nurses with digital skills and knowledge. Ubuntu’s ethical framework will ensure digital inclusion, equity, participatory decision-making, a sense of belonging, consensus, and mutual respect. Without proactive strategic self-reflection, planning, and action, nursing will fail to control its digital trajectory. The continuous development of nurses should also prioritize digital skills. Eventually, this will help to address and minimize the ethical challenges posed by digital technology.

Acknowledgments

This chapter was written during a writing retreat which was funded by the National Research Foundation in South Africa through the Ubuntu Community Model of Nursing Project at the University of Pretoria.

Conflict of interest

None.