Analysis of the nursing response

Commonalities exist within each of the seven articles supporting the deployment of a personal discourse of delirium. Evident in each of the papers is the desire to derive some understanding of the experience of delirium from the perspective of an older adult. Surfacing these otherwise marginalised discourses acknowledges that a set of ‘truths’ exist outside the realm of the dominant biomedical accounts of delirium. As a result, these published works act to decentre biomedical knowledges of delirium. The publication of the personal narratives inherent within this discourse is not only a major imperative of this thesis, but also constitutes a central position intrinsic to a critical gerontological epistemology (see Gubrium, 1993; 2001).

The papers presented above clearly identify the heterogeneity associated with older people’s experiences. The authors attribute the diverse representations associated with having delirium as being shaped by the older adult’s social, cultural and historical backgrounds, and experiences. Also apparent in these articles is the importance of incorporating into the nursing care provided to this group of people, communicative and other relational activities, such as forming and maintaining a therapeutic partnership. Each of these findings draws on and relates to the core activities associated with

working as a gerontological nurse, for example the utilisation of the principles associated with holism as a basis for guiding nursing practice (Eliopoulos, 2005; Tagliareni, Waters & Anderson, 2003).

A variety of research methodologies have been used across each of the papers considered, including a case study approach, grounded theory, phenomenology through to the beginning use of narrative inquiry. Clearly Andersson et al. (1992; 2003), Andersson, Norberg et al. (2002), Laitinen (1996), McCurren and Cronin (2003) and Schofield (1997) sought to elicit the individual experiences of being delirious, as mentioned earlier. While these published accounts provide an important shift in what is known as the ‘truth’ about delirium, they also signify a cursory and romantic concern with the subjective experience of being delirious as an older adult.

Silverman and Bloor (1990) note that many writers in the field of gerontology have become preoccupied with the romantic notions of illuminating personal meanings and lived experiences. Analysis of the seven articles outlined above suggests just that and I question whether their research has merely displaced the medical gaze from a biological understanding of delirium to include a humanist understanding of person’s illness. This is supported by Gubrium (1993) who identifies these developments in the field of ageing as viewing “… patient-centered medicine as a kind of romantic reaction to body- centered medicine”.

The above discussion highlights the risk of biomedicalising the subjective experience of being delirious. Research methodologies, such as phenomenology, perpetuate the myth that the modern subject is capable of being an autonomous and self-conscious rational being, all of which share the same modernist ideals associated with biomedicine. Consequently “[S]cientism [biomedicine] would have us drown voice in objective context, transforming context into conditions without voice or, as is scientific habit, into standardized and measurable units” (Gubrium, 1993, p.61).

The article by Andersson, Hallberg et al. (2002) attempts to disrupt, decentre and resist the discourse of delirium as a syndrome through the use of narrative inquiry, a methodological lens aligned with critical gerontology (Cohler, 1993; Gubrium, 2001). The use of an unstructured interviewing style, as opposed to semi-structured, and the

understanding that the resulting narrative presented one possible experience, rather than an exact record of the delirious event is a significant theoretical shift in the area under investigation. Conducting research and publishing these findings alerts readers to other possible understandings of delirium; understandings that are fragmented and contradictory.

The emerging personal discourse of delirium, as depicted in the above reviewed publications, shares a similar focus to Kitwood’s (1997) work on personhood in the area of Alzheimer’s disease. Personhood highlights the psychological factors that may contribute to the manifestations of Alzheimer’s disease through the promotion of an “interpersonal psychology” (Kitwood, 1993, p.155). Parallel meanings shared between Kitwood’s (1997) work on personhood and a personal discourse of delirium, as described above, include the importance of communicative and therapeutic relationships, recognising differences in life and social contexts, and that each person’s experience is unique and should be valued as knowledge.

Four out of the seven articles identified as potentially representing a personal discourse of delirium, share the same authors (Andersson et al., 1993; Andersson, Hallberg et al., 2002; Andersson, Norberg et al., 2002; Andersson et al., 2003) and have been published over a 10 year period. The significance of this observation lies in the development of authors’ methodological thinking over time. The initial publication utilised a single case study approach, progressing to a phenomenological approach and culminating in the incorporation of narrative gerontological techniques inherent within, as already mentioned, a critical gerontological epistemology. This results in promoting local spheres of meaning around being older and experiencing delirium, thus opening up potential spaces for resisting biomedical constructions which focus on the unification of delirium as a stable medical entity.

However, the question remains; is this small collection of published research on the individual experience of being delirious as an older person indicative of what I have coined an emerging personal discourse of delirium? The analysis has revealed that indeed the literature reviewed is contestable, unstable and as a result problematic. While the findings of these studies could easily be dismissed by scientific communities as biased and invalid I think the commitment and tenacity required to publish qualitative

material in refereed journals, such as the International Journal of Geriatric Psychiatry, constitutes the beginnings of a personal discourse of delirium. The political act of printing personal accounts of being delirious by publishing institutions, such as the International Journal of Geriatric Psychiatry “… have facilitated the emergence of future discourses …” (Foucault, 2002a p.158). The emergence of future discourses is represented in the current study as a personal discourse of delirium.

5.5 Summary

In this chapter, the discourses evident in the nursing and medical literature have been explicated. Major representations of delirium in older adults, are vigorously present in the discourse of delirium as a syndrome. The authority of this discourse is particularly powerful, and I have demonstrated how the hegemonic structures of medicine have infiltrated nursing discourses through providing minimal opportunity to understand delirium, other than as an object of pathology.

The objectification of delirium largely overrides the nursing concerns for caring as it relates to the older adult. Reviewing the literature raised many questions for me about the silence of the personal experience of being delirious. However, the problematisation of the discourse of delirium as a syndrome has highlighted those discourses that exist at the margins of the biomedical discourses. One of these discourses I have identified as a personal discourse of delirium. While none of this literature critically analysed the dominant biomedical views currently circulating, their presence and availability does destabilise the discourse of delirium as a syndrome. In addition, this body of literature provides a platform for further development of a personal discourse of delirium.

This chapter marks the end of my engagement with the nursing and medical literature. The next chapter of this thesis shifts to the representations of people who have been delirious. Attending to the texts of older people who have been delirious deploys a personal discourse of delirium and further problematises the disciplinary practices inherent in the discourse of delirium as a syndrome. The importance of foregrounding personal discourses will be highlighted and juxtaposed with published documents that are influenced by the discourse of delirium as a syndrome.