Challenging Functional Decline As a Driver of Care for Hospitalised Older Adults: a Discursive Ethnography

Challenging Functional Decline as a driver of care for hospitalised older adults: A discursive ethnography Jeannine Therese Moreau A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy Sydney Nursing School The University of Sydney November 2017 ACKNOWLEDGEMENTS This thesis would only be thoughts on an airwave if not for the gracious and generous participants who came forward both enthusiastically and cautiously to consent to participate in the study. I deeply appreciate their enduring commitment to working with me day after day as I followed one patient after another. Each participant contributed for the most part with enthusiasm and a generous sense of curiosity. My two Supervisors Dr Trudy Rudge and Dr Sandra West were great, two amazing minds. Thank you both for your generosity of spirit as you were wonderfully supportive, shared ideas, albeit try as hard as I could, no sharing of “answers”. You stretched my thinking when I thought the elasticity was over but presto the emergence of insights and new ways of thinking, more rewriting and rewriting, albeit so very worthwhile. Thank you to colleagues who generously shared their PhD experiences, ideas, thinking and philosophical perspectives never mind a few rowdy discussions; thank you Olga, Denise and Rochelle in particular! Anne you have been and continue to be an inspiration as you engaged with me in some rather intriguing aha moments and terrifying although rewarding insights always with a side of laughter. Clare, you lived up to your name as someone who lit up my thinking with our great conversations as we reached for clarity in our wonderings about life, always refreshing. Thank you to Dr Andre Smith who was an important part of this journey as he made me aware of the danger of managing too many ballooning ideas at once, reminding me that logic and focus can be really key. I am also appreciative of the support and sustenance to keep on going provided by my colleagues and peers at the University of Victoria, School of Nursing and the Centre on Aging. Dear Frank, loving partner, you truly kept me alive, healthy and able to persevere despite thesis challenges. You carried me with your humour, wisdom, patience and yet pragmatic sense of just get it done. I have a deep and abiding appreciation and gratefulness for you being consistently present throughout the dark moments, difficult times and joys of accomplishment. i DECLARATION I certify that this thesis does not incorporate without acknowledgement any material previously submitted for a degree or diploma in any university; and that to the best of my knowledge and belief it does not contain any material previously published or written by another person except where due reference is made in the text. Signed: Date: August 25th 2017 Name: Jeannine Therese Moreau ii Challenging Functional Decline as a driver of care for hospitalised older adults: A discursive ethnography (Photo by Jeannine Moreau) “Oldness” is evocative of decay and uselessness …functional decline is not pretty. iii ABSTRACT Functional decline is considered a critical issue in health care incurring significant human and financial cost. In hospitalised older adults’ care, functional decline is defined pervasively as decreases in the level of socio-biophysical capacity for activities of daily living (ADL) such as personal care and mobility, that are understood to result in further functional impairment and loss of independence. The health care system is concerned about the associated prolonged hospital stays, diminished outcomes at discharge, and increased dependence and/or mortality. This thesis uses discursive ethnography to get up close to examine functional decline as a discourse (social practices that produce knowledge) focused on older adults’ decreasing capacity in the material actualities of hospital experiences. Seven patients, 75 years or older, hospitalised for surgical repair of a fractured hip due to a fall were followed from admission to discharge. Participant observations afforded a view into performances of care within nurse/patient interactions. Conversations and recorded interviews offering a place for older adults and their nurses to discuss the situation. Foucauldian discourse analysis explicates how assessment technologies, generated by gerontological research to predict which older adults at greatest risk for functional decline, are constituted by a functional decline discourse based on norms reproduced from ADL technologies. Production and distribution of this discourse in the literature and hospital contexts display how these technologies, when redistributed into hospitals are not benign in their effects, but as functional decline imbued discourses of care produce knowledge that normalises and drives nurse/patient interactions within everyday care: constituting nurse and patient subjectivities contingent on how it is taken up, resisted, or ignored, as nurses and patients position within such interactions. This thesis exposes how functional decline as a discourse acted to effect such positioning, eliding other knowledges, ways of perceiving older adults and enacting care. It provides new understandings that challenge such elisions and singular approaches to provide alternative positions more likely to provide patient centred hospital care for older adults, despite the pervasiveness of the hegemonic discourses that dominate and structure health care systems. iv CONTENTS List of Figures .............................................................................................................. viii List of Tables ................................................................................................................. ix Key to Transcripts .......................................................................................................... x Chapter 1: Introducing the thesis: the event of functional decline discourse .............. 1 Functional decline discourse: an introduction ........................................................... 3 Modernity, Geriatrics and Critical Gerontology: key thesis informants .................... 5 Geriatric practices as functional decline discourse: thesis context ........................... 8 Geriatric assessments ............................................................................................. 9 Geriatric syndromes ............................................................................................. 12 Geriatric teams and units ..................................................................................... 13 Geriatric models of care/programs of care .......................................................... 15 Locating Foucault in the thesis ................................................................................. 16 Engaging discursive ethnography as poetic practice ............................................... 20 What is under study ................................................................................................. 22 Structure of the thesis .............................................................................................. 23 Chapter 2: Ethnography in discussion with Foucault .................................................. 25 Writing the thesis: realisations of suchness ............................................................. 25 Archaeology: explicating structures and powers of discourse ................................ 28 Formation of objects, enunciative modalities, concepts and strategies ............. 30 Conditions of possibility: appearance of functional decline as discourse ............... 33 Bio-politics and Alarmist demographics ............................................................... 35 Governmentality ................................................................................................... 37 Neoliberalism ........................................................................................................ 39 Managerialist reengineering of health care: governing practices ....................... 40 Genealogy: what the doing of discourse does ......................................................... 42 One critical and three genealogical sets of analysis ............................................. 43 Discursive ethnography: methodological strategies ................................................ 48 Crisis of representation ........................................................................................ 48 Panopticon: metaphor for power and surveillance ............................................. 50 Thirdspace: interconnected spaces as productive of knowledge ........................ 51 The ethnographer’s body: a critical analytic tool .................................................... 53 Chapter 3: Methods: figuring research practices ........................................................ 55 v Entering the field: mechanics of the ethnography .................................................. 56 Constructing the hospital field site: a discursive affair ............................................ 56 The interior geography ......................................................................................... 58 Staffing .................................................................................................................. 59 Entering the field .................................................................................................. 59 The participants .......................................................................................................

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