How nurses understand and care for older people with delirium in the acute hospital: a Critical Discourse Analysis

Delirium is a common presentation of deteriorating health in older people. It is potentially deleterious in terms of patient experience and clinical outcomes. Much of what is known about delirium is through positivist research, which forms the evidence base for disease-based classification systems and clinical guidelines. There is little systematic study of nurses' day-to-day practice of nursing patients with delirium. The aim was to uncover the kinds of knowledge that informs nurses' care and to explicate the basis of that knowledge. Critical Discourse Analysis is underpinned by the premise that powerful interests within society mediate how social practices are constructed. Links were made between the grammatical and lexical features of nurses' language about care in interviews and naturalistic settings, and the healthcare context. Care focused on the continuous surveillance of patients with delirium by nurses themselves or vicariously through other patients, and containment. Nurses influenced by major discourses of risk reduction and safety, constructed patients with delirium as risk objects. The philosophy of person-centred and dignified care advocated in nursing literature and government policy is an emerging discourse, though little evident in the data. The current dominant discourses on safety must give space to discourses of dignity and compassion.     

A discursive exploration of nursing work in the hospital emergency setting

Emergency nurses apply specialist knowledge to the practice of emergency care. This paper discusses the ways in which three emergency nurses understand the nature of their care from their own frames of reference and experiences and presents some of the data collected in a larger study. Various discourses, which compete to inform emergency nurses' understandings of practice, are linked with the notion of nurses as subjects; that is, each discourse may inform, shape and constitute the practice of the nurse and, in turn, the ways in which the patient comes to be known and understood. I will examine the ways in which emergency nurses come to experience or position themselves vis-à-vis extant forms of knowledge of emergency care and the extent to which they articulate new or distinctive formulations of emergency care. This paper illuminates the commonalities that constitute the discourses of emergency nursing care, and also analyse nurses' language which demonstrates that within each discourse variations, contradictions and resistances exist. Emergency nursing care occurs in a context of a biomedical discourse that dominates, or tends to dominate, the work of the emergency setting and so to determine acceptable or possible practices. Nevertheless, nurses contest in various ways the 'truths' that they understand to underpin their practice. Challenges to biomedical discourses are revealed, to some extent, by drawing attention to specific situations and particular struggles encountered in emergency nurses' everyday practice.     

The nurse-patient relationship: a consideration of its discursive context

This paper is a theoretical exploration of the discursive context that shapes the nurse-patient relationship. It represents a feminist poststructural consideration of the broader institutional and social context that influences the dynamics of that relationship. The characteristics of that relationship can be regarded as performances of subjectivity shaped by managerial, medical and nursing discourses. Both nurse and patient signify particular discursively constituted meanings to each other which shape the relationship. It is proposed that the discourses which inform how each should respond to the other encourage the utilization of disciplinary tactics by the nurse which relay to the patient what is expected of him/her. An effect of these disciplinary procedures is to rein in the caring potential of nursing practices. However, nursing's relationship with women's work and the social history of caring may provide it with a discursive context that recognizes the social significance of this work.     

Methodology for social accountability: multiple methods and feminist, poststructural, psychoanalytic discourse analysis

Bridging the gap between the individual and social context, methodology that aims to surface and explore the regulatory function of discourse on subjectivity production moves nursing research beyond the individual level in order to theorize social context and its influence on health and well-being. This article describes the feminist, poststructural, psychoanalytic discourse analysis and multiple methods used in a recent study exploring links between cultural discourses of masculinity, performativity of masculinity, and practices of male violence.     

Organizing context: nurses' assessments of older people in an acute medical unit

The paper presents findings from a study of how older people are assessed and cared for in an acute medical unit. The aim of the study was to reconsider nurses' assessment practices in relation to organisational context. Drawing together ethnographic methods with discourse analysis, the study develops an approach to studying nurses' assessment practices and aims to demonstrate that nurses go beyond entering their relationships with patients as individuals. Rather, nurses' assessments of patients can be considered as processes of alignment that help nurses accomplish complicit managerial and medical objectives, and shape their own identities.     

The concept and practice of comprehensiveness in Primary Health Care: nurses' perception

The objective of this study is to debate on the nurses' discourse on the concept of health comprehensiveness and how to implement it in primary health care practice. Considering that comprehensiveness is one of the pillars of the Brazilian public health system (SUS) and taking nursing work force as a considerable commission of people to work for the construction of the SUS, the authors considered important to identify the conceptual bases and practices that guide nurses' work towards in the construction of health comprehensiveness. In this qualitative, exploratory study interviews were performed with 10 nurses working in primary health care centers in three cities in the interior state of S?o Paulo. Data collection was performed through semi-structured interviews and analyzed according to the collective subject discourse technique. Results showed that the nurses' conceptions on comprehensiveness are directly relates with providing care, and that these professionals put comprehensiveness into practice through their everyday work.     

Nursing in a technological world: searching for healing communities

A research dialectic between philosophy of technology and nurses' work in acute care surfaces parallel technological practices that threaten the healing nature of two modern projects: health care and ecological restoration. A metaphor of ecological restoration is used to explore the consequences of denatured health care work for the welfare of patients, families, practitioners, and healing communities. It is argued that in health care systems where the mismatch between treatment options and resources for care steadily grows, the nursing discipline must develop ecological literacy for a technological world.     

Delirium and older people: repositioning nursing care

Aims. To critically examine the nursing care offered to older people who have been delirious. Background. Delirium occurs as a result of physiological imbalances resulting in an alteration in consciousness and cognitive impairment. Delirium is a prevalent and serious cognitive disorder experienced by older people. While there is a vast number of studies published utilizing quantitative methods, there remains a dearth of research relating to delirium in older people from a qualitative perspective. Design. A qualitative research design that utilized a critical gerontological framework underpinned this study. This framework drew on aspects of postmodernism and Foucault's understanding of discourse. Methods. Data sources included published documents on delirium, semi‐structured taped interviews with people over the age of 65 years who had been delirious (as well as their clinical notes), family members, Registered Nurses and a hospital doctor. A postmodern discourse analytic approach was used to interrogate the 20 sets of data collected. Findings. Textual analysis revealed the presence of two major discourses impacting on being an older person with delirium. These were identified as a nursing discourse of delirium and a personal discourse of delirium. A nursing discourse of delirium was largely focussed on the biomedical processes that resulted in a delirious episode. Conversely, a personal discourse of delirium highlights that there are other ways of ‘knowing’ about delirium through considering the narratives of older adults, and their families, when offering a nursing service to this group of people. Relevance to clinical practice. Nursing needs to critically examine all aspects of nursing care as it applies to older people who have delirium to ensure the rhetorical claims of the profession become the reality for consumers of health services. The use of critical gerontology provides nurses with the tools to challenge the status quo and uncover the multiple, varied, contradictory and complex representations of delirium in older people. Inherent within a personal discourse of delirium is the importance of incorporating into nursing care communicative and other relational activities, such as forming and maintaining a therapeutic relationship.     

Why are nurses leaving nursing?

The causes of nurses' exodus from acute health care delivery practice may lie more in intrinsic factors rather than the heretofore overtly expressed reasons. This article examines bureaucratic factors, issues related to the medical profession and medical/scientific discourse, and factors within the nursing profession itself that may contribute to a nurse's unhappiness and dissatisfaction that causes him or her to leave. Nursing as emotional work and the implications for the individual nurse, and nursing as moral and moral distress are discussed. Suggestions to facilitate retention are made for changing the work environment to feel valued for their skillfully applied humanness.     

Constructing mentally ill inmates: nurses' discursive practices in corrections

The concepts of discourse, subjectivity and power allow for innovative explorations in nursing research. Discourse take many different forms and may be maintained, transmitted, even imposed, in various ways. Nursing practice makes possible many discursive spaces where discourses intersect. Using a Foucauldian perspective, were explored the ways in which forensic psychiatric nurses construct the subjectivity of mentally ill inmates. Progress notes and individual interviews constitute discursive spaces within which nurses construct patients' subjectivities. Progress notes provide a written (and permanent) form of discourse, while interviews set the space for a more fluid and contextual form of discourse. We identified five types of subjectivities - the (in)visible patient, the patient as risk, the deviant patient, the disturbed patient and the disciplined patient. These subjectivities were rooted in various types of discourses circulating in the selected setting. Despite the multiple discursive dimensions of forensic psychiatric nursing, progress notes remain the main formal source of information regarding nursing care even though it is not representative of the care provided nor is it representative of nurses' complex discursive practices in corrections.     

Northern nursing practice in a primary health care setting

BACKGROUND: This paper explicates the nature of outpost nursing work, and/or the day-to-day realities of northern nursing practice in a primary health care setting in Canada. The study was carried out to systematically explore the work of nurses in an indigenous setting. Institutional ethnography, pioneered by Dorothy Smith was the methodology used to guide this research. The theoretical perspective of this methodology does not seek causes or links but intends to explicate visible practices. AIM: It is intended to explicate the social organization of specific discourses that inform work processes of nurses working in remote indigenous communities. METHODOLOGY: The data originated from various sources including spending 2 weeks in a northern remote community shadowing experienced nurses, taking field notes and audio taping interviews with these nurses. One of the two researchers was a northern practice nurse for many years and has had taught in an outpost nursing programme. As part of the process, texts were obtained from the site as data to be incorporated in the analysis. The lived experiences have added to the analytical understanding of the work of nurses in remote areas. Data uncovered documentary practices inherent to the work setting which were then analysed along with the transcribed interviews and field notes derived from the on-site visit. Identifying disjuncture in the discourse of northern nursing and the lived experience of the nurses in this study was central to the research process. RESULTS: The results indicated that the social organization of northern community nursing work required a broad generalist knowledge base for decision making to work effectively within this primary health care setting. The nurse as 'other' and the invisibility of nurses' work of building a trusting relationship with the community is not reflected in the discourse of northern nursing. Trust cannot be quantified or measured yet it is fundamental to working effectively with the community. CONCLUSION: The nurses in this study saw building trust to promote health and well-being in communities as very important, yet very difficult to achieve. The difficulty in part stems from the constraining, structural, administrative, historical, cultural and political contextual realities that have shaped northern community nursing.     

Humanism in nursing: the emergence of the light

Humanism in nursing: the emergence of the light
This paper examines Western nursing practices by focusing on their spiritual aspect. The transformation of the informal and poorly trained nurse into the trained and uniform persona of the modern nurse is the subject of many nursing histories and part of nursing mythology. Using the work of Michel Foucault and Marcel Mauss, the nursing that preceded the 19th century reformers is re-examined and continuities between current and quite ancient practices of nursing are explored. The development of practices or technologies for care of the sick originated with the establishment of hospitals in the 4th century as part of pious Christian practice. Current practices of care and the discourse of holistic nursing are argued to have grown from these traditional Christian technologies of care. Humanist or holistic nursing represents the enshrinement of the Christian edios – freed of doctrine; the discourse of caring a redrafted Christian discipline of love.     

Educational silos in nursing education: a critical review of practical nurse education in Canada

Changes to practical nurse education (with expanded scopes of practice) align with the increasing need for nurses and assistive personnel in global acute care contexts. A case in point is this critical exploration of Canadian practical nursing literature, undertaken to reveal predominating discourses and relationships to nursing disciplinary knowledge. The objectives of this poststructural critical review were to identify dominant discourses in practical nurse education literature and to analyze these discourses to uncover underlying beliefs, constructed truths, assumptions, ambiguities and sources of knowledge within the discursive landscape. Predominant themes in the discourses surrounding practical nurse education included conversations about the nurse shortage, expanded roles, collaboration, evidence‐based practice, role confusion, cost/efficiency, the history of practical nurse education and employer interests. The complex relationships between practical nursing and the disciplinary landscape of nursing are revealed in the analysis of discourses related to the purpose(s) of practical nurse education, curricula/educational programming, relationships between RN and PN education and the role of nursing knowledge. Power dynamics related to employer needs and interests, as well as educational silos and the nature of women's work, are also revealed within the intersection of various discourses.     

Power and partnership: a critical analysis of the surveillance discourses of child health nurses

AIMS: To explore surveillance discourses within New Zealand child health nursing and to identify whether surveillance practices have implications in this context for power relations. BACKGROUND: In New Zealand child health nurses are called Plunket nurses, who are employed by a voluntary organization, the Royal New Zealand Plunket Society (RNZPS). These nurses primarily work in the community with the families of new babies and preschool children. Their work is called child health surveillance and this is considered to involve routine and unproblematic practices, which are generally carried out in homes and clinics in the context of an ongoing relationship between the Plunket nurse and the mother of a baby. However, suggestions in the literature that surveillance, wherever it is practised, has implications for power relations cast doubt on official claims that this nurse-mother relationship is mediated through a partnership model of care. METHODS: Five experienced and practising Plunket nurses were each interviewed twice. The texts generated by these semi-structured interviews were analysed using a Foucauldian approach to critical discourse analysis. RESULTS: In contrast with the conventional view of power as held and wielded by one party, this study revealed that, in the Plunket nursing context, power is exercised in various and unexpected ways. Although the relationship between the mother and the nurse cannot be said to operate as a partnership, it is constituted in the nurses' discourses as a dynamic relationship in which the mother is actively engaged on her own terms. The effect of this is that it is presented by the nurses as a precarious relationship that has significant implications for the success of their work.     

Nursing academics’ languages of legitimation: A discourse analysis

Aim

To identify the proclaimed bases of Irish nursing academics’ identities as academics and to interrogate the ways in which they legitimate nursing as an academic discipline.

Background

Six years after pre-registration nursing education in Ireland transferred to the higher education sector, tensions continue to exist concerning the status and legitimacy of the discipline and those who claim to profess it.

Method

The languages of legitimation of senior nursing academics were elicited in the deliberately argumentative conversational context characteristic of many discourse analytic studies. These languages were analysed in terms of four of the building tasks of language: knowledge, politics, relationships and identities.

Findings

Irish nursing academics are unable to credibly and convincingly resist representations of their discipline as lacking legitimacy in academia. Indeed, they themselves construct academic nursing as a fragmented field, prone to colonisation and subversion by a plethora of other discourses, including medical, management and industrial relations discourses.

Conclusions

Senior nursing academics in Ireland need to urgently consider how nursing in the academy can reconfigure its relationships with clinical nursing, increase its intellectual autonomy, enhance its internal coherence and cohesiveness, strengthen the epistemic power of its knowledge base and critically evaluate the ways in which past practices inform its present, and whether and to what extent they should shape its future.