Challenging Functional Decline as a driver of care for hospitalised older adults: A discursive ethnography

Abstract

Functional decline (FD) is considered a critical issue in health care incurring significant human and financial cost. In hospitalised older adults’ care, FD is defined pervasively as decreases in level of socio-biophysical capacity for activities of daily living (ADL) such as personal care and mobility, 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 explicated how assessment technologies, generated by gerontological research to predict which older adults at greatest risk for FD, are constituted by a FD 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 FD 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 FD 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.