I have found myself on a journey that I can no longer avoid. In 1992 I gave an inservice on language to a group of staff nurses on a pediatric unit in a large, teaching hospital. I was then a student in an MSN program (Pediatric Clinical Nurse Specialist Track). The focus of my talk was refraining from calling patients by their diagnosis (the “appy” in room 3 or the “sickler” in room 25, etc.).
I have since chosen a career in diabetes education and management, and twenty years later I am amazed at how often I see and hear the word “diabetic.” I was giving an inservice (on diabetes) to nurses who provide staff education and was amazed at how many negative and judgmental words I heard. Open up any journal, book, magazine, blog, and it’s impossible to avoid seeing this kind of language.
The health care system has been trying to evolve for years (giving some credit here), from one that is paternalistic, controlling, and about healing the sick, to one that is accepting, supportive, patient-centered and about preventing disease. From one that is about the provider to one that is about the patient. But we are not there yet. And our language is, in my opinion, one of our biggest barriers. We need to talk the talk before we can walk the talk.
Words that come to mind include “compliance,” “must,” “should,” “have to,” “need to,” “I want you to…,” non-compliant,” any word that labels a patient (diabetic, asthmatic, leukemic, sickler, and so on), “control,” “good/bad,” and many more that I can’t think of at the moment.
I truly believe that words matter. Even the most caring nurses use words/phrases that hurt – mainly because they “grew up” using them, and often because it’s just faster and easier to use them. But patients deserve to hear words that build them up (strength-based) and put them at the center of their care (patient-centered). Patients deserve to be thought of, approached, and addressed as human beings with a lot more to them than a disease, illness, infection, procedure, or what have you. And it’s true for conversations about patients as well (for instance, at the nurses station or during report).
Those of you who work in health care settings probably (undoubtedly) hear these and more words/phrases every day. You may even have become immune to them. Can I ask a big favor? Can you pay close attention in the upcoming days/weeks, and jot down any judging, negative words/phrases you hear? Could you then come back to this blog and post the words in the comments section? Thanks for your help with this little project! I would also love to hear your thoughts on how we can change the language that is used in health care.
NurseManifest 
Hi Jane,
As so often, I agree with you – though my sleep-disrupting languaging concerns tend to be a bit different. 🙂
So I tend to think about the languaging of financial relationships between nurses and patients/clients.
So, a pre-managed care/capitation introduction might go like this and may still be used inappropriately today:
Hello Mr/Ms/Miss/Mrs X. I am your nurse. I will assist you in any way I can without regard to your condition, ability to pay or third party payer interests. I will be your caregiver and advocate even if it causes friction in my organization because that is what being a nurse means.
While a post-managed care/capitation introduction might go like this:
Hello Mr/Ms/Miss/Mrs X. I am your nurse. I will assist you as long as your needs do not exceed the average costs for patients in your condition. I will be guided not by your unique condition and needs, but by directives established by the finance department based on contracts negotiated by them. I will balance your needs against the needs of all other patients, mindful of the costs I will be held accountable for during your stay, throughout each financial period and my entire career.
or, far more honestly and perhaps with appropriate legal disclaimers:
Hello Mr/Ms/Miss/Mrs X. I am your nurse. But of greater importance to your health and well being, I along with this facility, your doctors and other caregivers are your health insurer. While I an technically a nurse, there is scant attention given within my organization to the quality of care I provide and a great deal of attention on the costs of care I provide to each patient.
In rendering care, I will usually go along with directives from finance and established protocols regarding limiting referral for treatments, diagnostic tests and I will adhere to corporate imperatives to speed up your discharge planning.
In very rare circumstances I will be your advocate, but the costs for me be will be very high and I will not do this for most of my patients no matter how dire the circumstances or consequences may be.
I will be held accountable for the costs of your care by my manager, the nursing supervisor and the Chief Nursing Officer, Chief Financial Officer and Chief Executive Officer. I do not like this but this is the face of 21st century nursing
I have had many friends and colleagues who have been fired for advocating for their patients. I will be mindful of your needs, but also of other patients and employees, my own career and my family. Given those constraints I will do what I can to help you but I have many other patients, the staffing here is inadequate and supply shortages are common. I cannot even be sure that I will be your nurse throughout the next 8 hours because nurses are routinely sent home when patient censuses fall and I could be assigned to different patients, a different unit or even be sent home before the end of my shift.
Within the context of these constraints and the obvious financial and ethical conflicts they entail, I will do what I can for you. But it will be better if you do not expect too much from me, or this facility, because our roles as your health insurers are far more important than our roles as your caregivers.
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Ok, Thomas. Now I’m completely depressed. What can we do to change this? This is not what nursing is all about. Carey – if you’re reading this, how does this dovetail with the transformation/revolution discussion? How can we transform if health care doesn’t allow it? Yikes.
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But I will add, on a lighter note, that we CAN adjust our language (see original post) and make it non-judgmental, patient-centered and strength-based, despite the circumstances you describe in your comment. It’s not the patient’s fault, after all :).
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🙂 That’s an interesting issue.
Is it the patient’s fault if they elect health plans that lead to inadequate care?
Is it the fault of nurses who are willing to work in the thousands of non-magnet hospitals where the worst clinical inadequacies are perpetuated?
The answer I suspect is that we are all guilty as sin and all innocent as lambs.
As always, the most radical, most transformative thing any of us can do is to understand the things we think we either already understand or which we assume we do not need to understand.
Central to the problems faced by nurses and patients are subtleties involved in health care finance systems that virtually no nurses and few patients understand at all.
But, as I have found the last few years, it is extraordinarily difficult to lead nurses and patients to the fountain and to encourage them to drink.
But, ever hopeful, I do have a website devoted to the problem of insurance risk transferring health care finance mechanisms…
http://www.standarderrors.org/
🙂
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Hi, Jane, I think the more we practice self care and reflection, the more we become aware, we can begin to pick up on the use of our language and the implications. Since I teach mostly online, I see students come into the classroom with these language issues and we often point them out, how they are “othering” patients.
In face face class I had a student say she was feeling burned out and when triaging an ER patient who was likely drug seeking she wanted to take the pen and stab her in the eye. Ummmmm… wow. But I think this brought out a lot for her, being able to state how she felt and she did start doing a lot more self care including massage and exercise, as well as the required reflections in the course to get into her deeper issues around burnout. I do think that the system keeps us stuck somewhat, but I think we can change by first practicing that self reflection and next striving toward creating a caring-healing presence in all we do. I see my students struggle with it and also have some good success, but we keep striving….
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Great points Carey. Makes total sense. I will work on incorporating more self-care promotion in my classes. Thanks for sharing your insights!
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