Writing patients, writing nursing : the social construction of nursing assessment of elderly patients in an acute medical unit
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The study examines nursing assessment in the context of questioning how nurses' encounters with patients become occasions for nursing. The focus of the study is on those occasions which constitute nursing assessment, in recognition that these occasions cannot be detached from other aspects of nurses' conduct. To undertake this examination of nursing assessment, I have drawn on the work of Michel Foucault, with an approach to field research and the analysis of discourse which has developed from contemporary writings on communication, anthropology, ethnomethodology and ethnography. With its focus on examining how power effects are constituted within an acute medical ward, the position developed in the thesis seeks to integrate critical thinking in ethnography with a post-structuralist problematising of 'detachment' as an everyday feature of social conduct. There are three parts to the study. The first part entails a textual analysis of how nursing assessment has been written in the literature. Nursing assessment has been conceptualised as a component of the nursing process; as a technical and cognitive activity. Representing nursing assessment in this way raises issues of knowledge and power. Writing nursing in terms of information processing, problem-solving 'models' is however less a representation of nursing reality and more a discursive practice, one with its own domain and locus of action. The nursing process detaches nursing assessment as a technology, separable from the organisation of patient care and autonomous from the social, but one designed to reconstitute the social through making nursing thinkable in a particular epistemic space. The second part of the study, a detailed examination of the care of old people in an acute medical ward, suggests the particular development of nursing assessment as a cognitive and technical activity overlooks the heterogenous conditions in which nursing is practised, in which it is being written and in which the conditions of detachment that the nursing process, once in process, helps produce and reproduce. These include involving an instrumentalrationalist approach to research on health services, a managerialist climate which seeks to make nursing 'visible' in relation to cost and time; the professionalisation of nursing, which impacts on nurses as a call for nurses to make nursing 'professional', rational and distinct from other practices; and, instituted through fashionable talk of customer care and the care of the subject, a heightening of persons as individuated, accountable, knowing subjects. The analysis shows how the disposal of elderly persons is effected by nurses through a 'constituting of classes' and explicates the motility of these classes in response to the aforementioned pressures. The final part of the thesis develops these themes. The nursing process appears to give the burden of knowing to the nurse as expert, always saving itself from appearing to be a congenitally failing technology through appeals for more and better training. Far from this being so, I illustrate how the burden of knowing falls upon the person; how as patient, persons must detach themselves from their everyday experience and seek modes of conduct appropriate to their disposal. By writing nurses as rational, scientific and professional practitioners, I suggest how the nursing process has been developed as a control technology which both disciplines patients to help accomplish their disposal and manage nurses through the institution of new forms of accountability and self-discipline.