Falls and falling as explanations concerning health and self in older people

Abstract

Falling in older people is currently represented as a significant problem warranting attention, in health care research and practice. Within this thesis, discourse analysis is employed as an underpinning methodology to explore this assertion.

An initial literature review suggested that most research to date in the area of falling in older people is based on three problematic assumptions; that a fall is a serious event for an older person; that it is possible to establish an objective reality about causes and consequences of a fall; and that it is possible to prevent a fall.

An initial empirical study aimed to explore how occupational therapists, physiotherapists and older people who had fallen talked about falls and falling. Semi-structured interviews were conducted with a purposive sample and twenty therapists from two NHS trusts, and eight in-patients aged 65 years with fractured hips (shown to be closely associated with falls), consecutively recruited from an acute elderly care orthopaedic trauma ward over a two month period.

Analysis and interpretation based on discourse analysis principles, suggested that risk featured prominently in therapists' accounts of their work with older people who fall. However, the older service user participants focused on presentation of themselves as deserving, not culpable for their fall, competent and able to manage at home.

Following consideration of theoretical approaches to the study of risk, a second empirical study aimed to explore how risk was invoked, communicated and managed in a day hospital for older people. Data were generated through fifty hours and fifteen minutes participant observation, semi-structured interviews with fifteen older service users and documentary sources, and again analysed according to discourse analysis principles. It was suggested that activity and interaction within the day hospital could be variously cast within three 'frames': the 'medical', 'rehabilitation' and 'social' frames. Risk was constructed within the three frames as threat of bodily harm, threat of loss of independence and challenge to valued social identities, respectively.

Falls in older people were retained as an exemplar in subsequent discussion to illustrate how risk in health has been constituted in technical, positivist terms (or within 'medical' and 'rehabilitation' frames) to the exclusion of social and cultural explanations. It is argued that this has resulted in health care and health promotion activities which fail to recognise older service users' perspectives and priorities and neglect implications for older peoples' social identities.

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