Interdependence revised: co-creation as new pathway

Persons who depend to a large degree on daily care from others, like residents of a nursing home, are at great risk of being hurt in their uniqueness. One important source for reducing this risk to a minimum offers nurses’ daily and concrete care. That care can preserve someone’s identity. If so, nurses’ care can be described as preservative care.

Although this philosophy of nursing care is based on the acknowledgement of human interdependence, it depicts nurses merely as independent caregivers and nursing home residents as dependent care-receivers. This description does not value the full potential of interdependence. Co-creation as a value and practice offers a new and workable approach of a true recognition of human interdependence.

Preservative care ((1))
The vulnerability of nursing home residents demands a special kind of protection. Nurses are in a unique position to offer this protection by continually attuning their care to a particular person in a particular situation. In protecting others through care, nurses are preserving their personhood. This expression of protection is called ‘preservative care’. Preservative care involves creating a situation whereby the person experiences a sense of recognition and acknowledgement as an individual. Sustaining continuity in personhood may preserve a person’s ‘known’ identity, but it may also have the painful effect of accentuating that it has been lost forever. Therefore, preserving someone as a unique person should also entail keeping the door open to a process of ‘becoming’ a ‘new’ identity.

Tronto’s  model ((2)) is used to establish four phases of preservative care: (1) caring about, (2) taking care of, (3) caregiving, and (4) care-receiving. Preservative care is expressed by the caring behaviour of the nurse during the actual interaction with a nursing home resident (phase 3). The remaining three phases (noticing in passing new or different care needs, organising or adapting care on the spot, and reciprocal interaction during care-receiving) can also be discerned in this third phase.

After its publication in 2011, this philosophy of care was introduced in a Dutch professional nursing journal ((3)) and served as a key reference for a textbook on good daily nursing care.((4)) Moreover, the philosophy of preservative care has been studied empirically as a source for the support of undergraduate nursing students’ development in person centred care.((5)) In the field of ethics, the Dutch ethicist Frits de Lange elaborated on this philosophy in his work on preservative care. ((6))

Interdependence revised
Despite an emphasis on interdependence, the majority of the contributions in the field of care ethics describe human beings as either independent (caregiver) or dependent (care-receiver). This binary approach also dominates the nursing literature: nurses are independent caregivers and patients are dependent care-receivers. Equally, narratives from nurses (‘we are the ones who take care of others’) and people residing in a care facility like a nursing home (‘we are the ones cared for by others’) do not justify the interdependence of humans in professional care settings. As a consequence, nursing home residents seem to be deprived of their willingness to take care for each other.((7)) Likewise, nurses are not considered as care-receivers depending on care from colleagues, residents, volunteers or any other member of this community. This might be ‘countered’ by a story ((8)) of co-creation that recognises and gives room to the full potential of interdependence.

If care is a practice of interdependent people who are intertwined in processes of noticing, organising, giving and receiving care, than each person of this practice is a potential observer, organiser, giver, and receiver of care. Although the positions of members in a caring community differ, each of them is and remains to a certain degree dependent and independent in different domains of life. One way to acknowledge persons’ interdependence is provided by co-creation. Co-creation is when persons relate to each other and interact in defining, designing and implementing a particular service, product or practice.((9)) In my proposal, co-creation is both a value and a practice. As a value, it recognises the necessary and unique contribution of each individual person, regardless of level of dependency, independency and vulnerability and position in a particular care practice, to what is experienced, described and valued as care. As a practice, it entails the actions, thoughts and emotions of all actors, including their experiences, dreams and aspirations. It requires skills, methods, and moral qualities like willingness, attentiveness, responsibility and responsiveness. In settings like a nursing home, co-creation may support the inclusion of all members of this particular community, including those who are known as residents, their families and volunteers. It will challenge and support a caring community in its search for a true acknowledgment of each other’s mutual interdependence to constitute a world in which all members flourish.

1 This section is based on Jukema (2011).

2 Tronto, J.C. (1993). Moral boundaries. A political argument for an ethic of care. New York / London: Routledge.

3Jukema, J.S. (2012). ‘Uniek zijn, uniek blijven. Aandacht voor individualiteit in bewarende zorg’. [Being unique, remaining unique. Attention for individuality in preservative care] Denkbeeld. Tijdschrift voor psychogeriatrie, 24 (1), 26-28.

4 Cingel, C.J.M. van der & J.S. Jukema (2014). Persoonsgerichte zorg. Praktijken van goede zorg voor ouderen. [Person-centred care. Practices of good care for older adults. A textbook for nurse assistants] Houten: BSL.

5 A case study revealed how two undergraduate nursing students took help from preservative care as a framework in their development: Jukema, J.S., N. van Veelen & R. Brinkman (2015). ‘Students experienced help from preservative care. A reflective case study of two nursing students caring from a nursing framework on good care’. International Practice Development Journal. 5 (2), Article 6. doi:10.19043/ipdj.52.006. Available at

6 Lange, F. de (2015). Loving later life. An Ethics of Aging. Grand Rapids MI: William B. Eerdmans; Lange, F. de (2011). In andermans handen. Over flow en grenzen in de zorg. Zoetermeer: Meinema.
7 A small, qualitative descriptive study indicates the willingness of nursing home residents to care for each other, but not knowing how to do act in accordance with this. Toebes, A. & J.S. Jukema (2014). Zorg voor elkaar: actief zorgend burgerschap van kwetsbare ouderen in het verpleeghuis. [Care for each other. Active citizenship of vulnerable older people in nursing homes] Geron, 16 (4), 42-44.
8 Lindemann Nelson, H. (2001). Damaged Identities. Narrative Repair. Ithaca: Cornell University Press.
9 Based on: Prahalad, C. K., & V. Ramaswamy (2004). Co‐creating unique value with customers. Strategy & Leadership, 32(3), 4-9.


About the author: Jan Jukema

Jan Jukema

Jan S. Jukema (PhD, MscN, BScN, Cert Ed.) o1967 lives in the Netherlands and is currently professor of nursing at Saxion University of Applied Sciences (NL).[]
Dr. Jukema holds a PhD in nursing science (Utrecht University), a master’s degree of science in nursing (Maastricht University) and a bachelor degree in nursing (NHL University of Applied Sciences).
His expertise is in the field of co-creation with older persons; shared decision making; Practice Development; person-centered care; and gerontology education.