Homecare & frail older people: relational extension & the art of dwelling

This paper is exploratory, and mainly discursive. Drawing on a number of sources, it explores home and care in terms of relational extension, keeping, and the art of dwelling

Creating text, analyzing text: a note on ethnography, writing and power

The paper shows how ethnography specifically helps us to examine the relationship between discursive practices, conduct and identity-work, and the appearance and reappearance of stabilities. It explores how the creation and continuous rewriting of an ethnographic text draws upon many different registers of social life, including interactions over time and across many differently situated occasions. Using examples from the domain of medicine, the paper shows how by examining the conduct of nurses, doctors and patients as they occur across a variety of 'differently situated occasions', we can examine the multiplicity of discourses available for members to ground their moves. The paper illuminate a process of analysis and writing that helps elucidate how members, through enrolling what is available, become enrolled and align themselves within networks of interest. What we find is not just routines and repetitions, or even deviations from norms and infractions, the foundations of structural relations of power; nor do we find fluidity, an idea that anything goes. Rather what we find through a particular approach to ethnographic writing is ‘motility’: the ways in which participants switch discursive domains and move the world. By pressing attention to motility the different moves members make can be shown to help re-accomplish socio-cultural relations of power. The approach described thus could be called post-structural rather than post-modern ethnography

Writing patients, writing nursing : the social construction of nursing assessment of elderly patients in an acute medical unit

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

The gene, the clinic and the family: Diagnosing dysmorphology, reviving medical dominance

This book is rather like the clinic, a space of crossing and translation, between medical sociology and science studies, both anthropological and sociological. Thus the book draws attention to and helps deconstruct the dichotomy between the laboratory and the clinic, and between science and medicine. The book draws on 25 years as a medical sociologist, researching acute medicine, primary care, accident and emergency, intensive care, paediatric genetics, geriatric medicine and biomedical science. My ‘ethnographic’ immersion in medicine and health care practice, however, began earlier by working for ten years in the British National Health Service, as a cleaner and nursing auxiliary in a geriatric hospital before I trained and practiced as a nurse and ward sister in both acute and primary care settings. While my close reading of the discourses of science and medicine owes much to my original training in English at the University of London, I have tried never to lose my grounding in everyday practice, my experiences with patients and that eye for detail that served me so well in those early days. The core research material comes from a longitudinal study of an evolving discursive practice in medical genetics known as dysmorphology. This is the study of abnormal forms, historically called congenital abnormalities. Thus the analysis of the book locates itself in those effects in persons identified as "existing from birth" and as relating to genitus, or "begetting". As it happens, dysmorphology’s roots are in paediatrics and the objects and subjects of clinical practice are mainly children and their families. Indeed many clinical geneticists I met were trained in paediatrics and the underpinning discourses in the clinic are the science of growth and form in humans, such as embryology, and conceptions of child development. Critically, dysmorphology is concerned with the description and recognition of ‘syndromes’. At the time of the study there were over 3,000 syndromes recorded in databases, and many of these descriptions were still in the making. So the book is to some extent about shape and form in contemporary medicine; and, further, how deviations from normal human development are being identified and named. ‘Dysmorph’ literally means misshapen, and is concerned with begetting when the coming together of processes of reproduction go wrong and do so in ways that produce abnormal forms. It should be noted that these syndromes typically involve very small numbers of people, and come under the new rubric rare disorders. Consequently, the availability of molecular and cytogenic tests was limited. The field of dysmorphology is also emerging at a time, the first decade of the new millenium, when biological understandings of the genetic and the congenital are changing and shifting. Hence dysmorphology is also busy relocating in relation to those understandings. Like biology, and no doubt because of its direct links to the biology of human development (specifically growth and form), dysmorphology is becoming more and more engrossed in the correlations between the genetic and deviations in growth and form. In so doing, dysmorphologists claim to be helping to shape the science of human development. So the first story I have to tell is about how the relations between medicine and science, the clinic and the gene, are in the process of being constructed in dysmorphology and in genetic medicine. We might think these syndromes may simply re-present difference – difference in one set of children and their parents from another; that where these differences are associated with pathology and reconstituted as problematic, what we have is a case study of abnormality or deviation that walks the tightrope of identity politics. What emerges however is how the genetics of normal human development relies on this mapping of deviations in growth and form, with the observation and description of congenital abnormality. So much so, that what seems to be evident is that it is the normal that is itself shrinking. So that, as one geneticist put it to me: from his perspective, we all have a syndrome. But what is so extraordinary is how in these new kinds of medical entities, syndromes, something so tiny as genetic mutation is being held responsible for the extraordinary disruption seen in some children’s physical and intellectual growth and development, and across so many of their bodies systems. This brings me to the second story I have to tell, which is about how we are all becoming drawn into these studies on growth and form and how the findings in dysmorphology are likely to affect choice of partners and alter decisions about procreation in the future. The critical issue is thus of grasping the significance of these imaginaries – syndromes and other forms of classification - through which forms of life get constituted as malformations; and, further, understanding when and why they bother us, literally and conceptually. What matters is what we do with these imaginaries, particularly in terms of ideas of family and relatedness, of personhood and conceptions of what it is to be human. A third story concerns my interest in how medical power works. What I help to show, contrary to the predictions of other observers, is how medicine is retaining its dominance in society partly through the clinic. In a large part this has involved me in recognising that the power of medicine rests not so much in its ability to help generate cures – important as these discoveries are – but rather in its sticking to classification and the method of doubt as forming the twin bases of science. What I hope to show is that medical power works as much through deferral as decision; and that this is what helps to retain the clinic – with its intimate links to the family - as the final arbiter

Homecare & frail older people: relational extension & the art of dwelling

This paper is exploratory, and mainly discursive. Drawing on a number of sources, it explores home and care in terms of relational extension, keeping, and the art of dwelling