On the margins: nurses and the intermittent care of people with dementia : a discourse analysis : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, Palmerston North, New Zealand
The purpose of this research has been to explore the representations and practices of nurses in the context of intermittent care for people with dementia, and to situate their accounts within the wider discourses of dementia care. Discourse, as explicated by Michel Foucault, is the body of knowledge, and the related disciplinary practices, that can be considered to be the truth at a particular time, shaping what is possible to be said, and with the associated power to exclude what cannot be said. In the first section of the thesis it is argued that the concept of dementia is not the description of some pre-determined biological phenomenon but a powerful disciplinary construction informed by a specific historical and cultural perspective, a construction that has major policy implications and ramifications for the representations of dementing illnesses in disciplines such as nursing. Section two of the thesis shifts from the disciplinary representations of dementia produced in published texts, to the representations and everyday practices of the nurses and families who participated in this study. While all the nurses' texts represented the care of the person with dementia as problematic, at times, in the institutional setting, there was considerable diversity apparent in nurses' discursive positionings, and in the associated practices and inscriptions of the person with dementia. The organisational context emerged as a major factor influencing those discursive choices and practices. One research site provided particularly successful respite care as judged by family caregivers' expressions of confidence in the service. The dominant nursing discourse in this site framed the hospital as home-like and the relationship with patients as being family-like. The permeability of social and geographic boundaries at this research site signaled inclusion for family and patients in contrast to the more traditional boundaries demarcating social and physical spaces evident in the other sites. This study highlights the institutional bases of powerful discourses such as biomedicine as well as the existence of alternative discourses. The marginal discourse of care as being family and home-like may lack the authority of biomedical and formal nursing discourses, situated as it were outside the academy, but space is provided in this representation to produce a social environment, and nursing practices, that encourage a sense of relationship and social inclusion for people with dementia and their family caregivers. Dementia has proved to be a fruitful area of study in that the current dominance of biomedical knowledge in nursing literature can be challenged as being marginal to nursing concerns. The subsequence discussion of how nurses have suppressed the knowledge and interests of people with dementia and, indeed, the knowledge of nurses themselves, provides a productive starting point for wider discussion about issues of power/knowledge in nursing representations generally.