Weighing our words: Language, nursing and reflective practice
Brian J. Brown PhD, BSc. (Hons)*
De Montfort University, Milton Keynes
Paul Crawford BA (Hons), RMN, DPSN
University of Birmingham
Karen D. Richards PhD, BSc. (Hons)
University of East London
Peter Nolan PhD, M.Ed., BA (Hons), BEd (Hons),
DN (Lond.), RMN, SRN, RNT
University of Birmingham
* Author for correspondence:
School of Social Sciences,
De Montfort University,
Holding a mirror up to caring? Language, nursing and reflective practice
This paper examines the language use in nursing with particular reference to mental health. Using Schonís ideas about reflective practice we show how a reflexive awareness of language use can illuminate and potentially transform three major areas of care: i) the use of Ďbaby talkí in the care of elderly clients; ii) how a clientís gender may impact on the construction of his or her problems; and iii) the impact of racial stereotypes on care planning for clients from different ethnic groups. As well as promoting equality in these three important areas, a sceptical, reflective awareness of language can assist nurses in making sense of the varied political and conceptual discourses which surround the profession.
Introduction: Getting to grips with language in nursing
Despite nursing being one of the most intensive 'people contact' jobs in existence, until recently the role of language in nursing has been curiously ignored by scholars and nurses themselves. Indeed, nurses may underestimate the role their language has in comparison to the technical aspects of their work. As Lou Van Cott notes: 'Several studies have found that many nurses perceive talking with patients as less important and less effective than the technical aspects of nursing care deliveryí However, the decade has seen some rapid changes in this area as nurses have begun to define their work in greater detail and have come under increasing pressure resulting from the newly restructured and economically aware health service in the UK. On the one hand there have been attempts to build up meticulously itemised classifications of nursing practice by bodies such as the International Council of Nurses and the North American Nursing Diagnostic Association, while on the other hand we see nurses grappling with the languages of management, accounting and economics which are rapidly colonising health care environments.
In this paper we will outline some areas of concern over the language used in nursing which are of contemporary importance, and end with an argument that consideration of language issues is a vital part of ethical, reflective practice. This will safeguard patients' interests and strengthen nursing's position in an increasingly competitive political environment. In Schonís seminal account of reflective practice, the aim was to turn indeterminate situations into determinate ones, through the development of concepts, languages and means of talking about what was previously tacit. This argument has been especially important within the caring professions. Following on from this we would argue that if nurses focus more strongly on language, its uses and powers, then they will be uniquely placed to take greater control of the orientation and direction of nursing. To illustrate the broad relevance of this approach we shall draw examples from our own and othersí research in three related areas dealt with by the caring professions where issues of inequality can be examined by means of close attention to the language used. The first concerns nursesí interactions with elderly clients, the second involves the different ways in which menís and womenís problems are conceptualised and the third examines how ethnic stereotypes are revealed through studentís accounts of psychiatric patients.
Ill-chosen words? communicating inequality
No matter how meticulously we try to define the language used in nursing a great deal of it will be difficult to scrutinise. This is because a high proportion of what happens in health care contexts is not done through technical vocabularies or decided on the basis of cost efficiency. Much of the language nursing staff use as they interact with patients, hand over from one shift to another, make reports and write records, is not technical but mundane language, prone to the same misunderstandings, inexactitudes and shortcuts that we find in everyday speech and writing.
One area where concern has developed over the speech styles of nurses and other carers is that of communication with elderly clients. This is an issue of growing importance as the population in industrialised countries ages. The little investigation conducted into how nurses interact with elderly clients has shown how misunderstandings are frequent and, more seriously, how nurses engage in 'secondary baby talk'. This is a form of over-accommodation where carers adopt the sort of speech that adults typically address towards young children. It assumes a greater degree of impairment of hearing and comprehension than is usually the case. When people in early or middle adulthood talk to older adults they are apt to use this secondary baby talk, involving exaggerated intonation and high pitch which simultaneously conveys nurturance and lack of respect. As scholars investigate this ethnographically, there has been more evidence of diminutive terms - 'that's a good girl', 'OK sweetie' and so forth. This is often done without regard to the patient's state of mind, so it is just as likely to be used on an alert, oriented elderly person as it is on someone who is confused. In any case, it does not necessarily improve communication with confused people. As well as being perceived negatively by elderly people themselves, in combination with other assaults on the person's dignity and independence, it may have more debilitating effects: 'Inappropriate or mismanaged communication can contribute to psychological and physical decline among the elderly'. It may be all too easy for nurses and other carers to slip into the style of 'secondary baby talk' because it is a way of managing people with multiple problems when nurses or other carers may not understand the underlying complexity of these problems. Yet we should also be aware that over-accommodated speech can contribute further to a patientís disabilities. Here, a reflectiveness about language has the potential to transform nursing practice and the situation faced by patients.
Giving form to patientís problems: The language of records
In addition to the potentially handicapping nature of speech, the records we keep in nursing deserve scrutiny since they have a disturbing tendency to escape from reality. Recording nursing practice should receive far more attention than it has so far. In addition to satisfying the increasing demands from patients and managers, this will also allow an important opportunity to reflect on what has been done for patients and what nursing means in practice.
The documentation which builds up around each patient who passes through the health care system may depend not only on the patients themselves, but will be informed by the prejudices, tacit theories and mental shortcuts that professionals take, as well as simple mistakes. The records taken in health care are never transparent descriptions of the patient, because even the structure of the record will impart qualities to the information which nurses ask about, document and describe in their routines.
Examining some of the records written by nurses working in mental health in our local area revealed some interesting contrasts. Our attention was drawn by two particular records, taken in the same handwriting, both applying to middle aged people who were suffering from anxiety conditions. One was a man and the other a woman. Curiously, the ways in which the records frame the problems is aligned with broader cultural beliefs about men and women. The woman's presenting factors on immediate contact are: 'Social factors- pressure at work,. . . [and] possible loss of home, and stress, leading to anxiety and depression'. So straight away we are presented with a number of aspects relating to the relationship between the individual and others which the nurse author is implying are causal. In contrast, the man receives a very different entry in the same place on the form which asserts: 'Anxiety... Agoraphobia - loss of confidence in ability to walk after a recent fall. Loneliness. Physical symptoms of anxiety...'. This is more about re-casting his problems in therapeutic terms. Within the first page then, the woman is defined in terms of relationships and circumstances and the man has technical problems. The heading 'social' on the form yielded some other differences. That is, the women's entry reads 'Sees son and his wife regularly....' whereas the man is described as a 'pleasant genial man....'. So again the man is accounted for in terms of individual characteristics and the woman in terms of relational characteristics. Yet both these individuals are described as suffering from some variant of 'anxiety'. These two cases show how nurses are able to construct versions of people and their problems. Although one could argue that both accounts of the patient are equally valid, it is important to note how these are not accidental or random variations. The pattern here bears out the suspicion by many feminist scholars that women are more likely than men to be seen in terms of relationships with others, and may indeed come to see themselves in this way. This recollects the way Kitzinger analyses the self-help and therapeutic literature that deals with the aftermath of child sex abuse. She locates in this literature an assumption that the women who have undergone this trauma should be aiming to resume heterosexual relationships and sexual activity when their recovery is complete. In other words, women's state of 'health' or 'illness' is conceptualised in terms of their relationships with others, whether this be middle-aged people with anxiety conditions or people who have been abused as children.
This is a theme which some feminist critics of the mental health system have identified. That is, if women are culturally supposed to be competent in interpersonal relations and overly reactive to stress, the womanís distress is both a psychological deficiency and an exaggeration of a stereotypical feminine tendency. The manís problems on the other hand look like a technical malfunction, which, because it can be given a diagnosis, is separable from his being a 'pleasant, genial man'.
Thus, even when we are dealing with items where choice is restricted due to the nature of the recording form, nurses are still able to exercise a considerable measure of creativity in deciding what to enter in the document. However, this is often a structured and bounded creativity which falls into line with broader cultural ways of making sense of men and women, as we have tried to illustrate. Social structures provide us with the rules and resources to navigate through everyday working lives. Once we become aware of the relationship between culture and everyday activity like note taking, we can begin to challenge it and consider alternative ways of making sense of patients, including the possibility that the patients may want to resist or transform the accounts which professionals construct for them. In this way, the reflective practice which an awareness of language facilitates can fulfil Schonís original stipulation that reflection should yield a kind of liberation, or transformation of power structures.
On a daily basis, nurses spend much more time with patients than doctors. Patients' behaviour is reported by nurses to other members of staff, and may achieve permanence in the form of written records. This information might then influence decisions made by doctors about the clinical management of patients. Each account provides a foundation upon which subsequent authors build, adding new chapters to and new interpretations of the patient's life. Written records, often packed with value laden or contentious interpretations, have a long shelf-life which can influence the patient's career even in the absence of the original author or any independent validation. Once a patient has been processed by the health care system, the labels they retain may result in stigma and discrimination, especially in the field of mental health. Moreover, staff sometimes believe the records in preference to the patients themselves. Oakley recounts how a doctor challenged a woman's knowledge of how many children she had when it did not tally with the file in front of him. Again, we would insert a plea for the importance of reflection concerning the durability and potential for harm involved in medico-nursing records. Perhaps, in line with Schonís original desire to exploit the transgressive qualities of reflective practice, we could argue for the importance of Ďpunctuating the texts with uppity voicesí that represent patientsí interests.
Making sense of patients: The development of psychiatric reasoning strategies
Let us look in more detail at an example from our own research to illustrate the importance of looking at language as a means of examining how health professionals like nurses construe the clients. On the whole, we would be very surprised if nurses nowadays displayed signs of overt racism. A professional group who have historically been at the forefront of pressing home the equal opportunities message in health care settings would typically present hostile ground for prejudice. However, despite displaying few overt prejudices, some disturbing qualities become apparent when the language they use is subject to scrutiny. This was brought home to us most forcefully when one of us gave a class of nursing students a variety of hypothetical case histories to comment on as part of a study aiming to investigate how they made sense of clients. The nursing students were invited to recommend a care plan for the patient and predict the likely outcome. Amongst these case scenarios was one of a young black man who had been brought into psychiatric care by the police. He was described by the nursing students as 'Going to need his behaviour restrained to protect others' and 'Delroy will need strong medication to reduce his violence.' He was also expected to try to smoke cannabis on the ward. By contrast, a young, white, middle class man whose psychiatric condition was being assessed after he had set fire to the university where he was a student was described in the following terms: 'I don't think Jonathan will appreciate being in hospital, it might make him worse' and 'The arson offence is an indication of the frustration or fear that he feels about his studies' and 'Jonathan's care plan needs to focus on counselling.'
The implications of this disparity are profound. Not only might it act to the detriment of patients but in the case of young black men, their hospital stays could be longer and the prognosis poorer as a result of the linguistic net within which they are enmeshed as soon as they enter hospital. The responses of the students to these scenarios effectively maintain the social narratives that construct both the hypothetical individuals and the racial groups to which they belong. These examples from our study are in accord with Lewis et al who found that psychiatrists were likely to judge African-Caribbean cases as more violent than white cases, and with Lewis & Appleby who found that young black males were readily perceived as a danger to others and were therefore recommended for stringent methods of control.
Our purpose in presenting these examples is not to pillory nurses, but to highlight the importance of looking at language and examining how it may affect patients and their future treatment within the health care system. Indeed, careful reflection on the language used in nursing is an important part of a developed ethical practice. Debate, questioning and the ability to provide rejoinders to what is said, written and reported within the profession is vital. In serious cases of verbal or written malpractice, where a patient or client is linguistically incarcerated or abused, nurses should feel fully justified in formally reporting that communication event. Terms of address and descriptions which are considered by the nurse to be offensive and damaging should be rigorously challenged. In this sense then, nurses' ethical responsibilities extend to other people's spoken and written texts. To choose not to hear or see detrimental nursing language is deeply unethical. Nurses need to be responsible readers and listeners as much as responsible writers. It is entirely consistent with the ethics of the profession and the ideals of reflective practice for them to grow more fully aware of the powerful effects of their written and spoken argument or viewpoint. At the same time, there is an ethical value in sharing a common responsibility to be sceptical about the speech and writing of all the various health care professionals.
We would urge individual practitioners to adopt a sophisticated approach to the language they employ. This is hand in glove with the value of reflective practice in nursing. The idea of reflective practice has been a feature of nursing curricula for some time, and what we are suggesting is its next logical mutation. Only by carefully monitoring their individual language actions are nurses able to become reflective practitioners. This is akin to consciousness raising in that it involves the development of concepts and languages to talk about and potentially transform what was previously taken for granted. Fundamental to all this is a belief that people can actually effect change, especially if they also believe they have the power to transform their situation.
The fruitfulness of this increasing reflection on practice depends on how far nurses can increase their awareness of the language they use to describe their work and professional aspirations, and their understanding of where the terms which have become the accepted currency of nursing debate have originated. The language of nursing contains many expressions and concepts imported from other disciplines such as medicine, psychology and management. In the 1990s particularly, the language of nursing was infused with changes resulting from a market-driven health service, users' movements and professional expansionism. The current focus on reflective practice attempts to address the problem of definition within nursing. Nursing is at a unique intersection of different languages. Scholars are trying to identify what kind of professional identity the occupation has as well as showing an eclectic desire for theories which can illuminate the process. In addition, some authors are documenting the unease which nurses may feel towards the infusion of management languages into the profession. Consequently, a major problem in trying to define the unique enterprise of nursing is that the language available to describe it is often derived from disciplines outside nursing. Reflective practice inclines nurses to critically examine these outside influences. The debate which this stimulates may yield a guarded acceptance or even a defensive response to the theories, languages and ideologies which find their way into nursing education and practice. It enjoins nurses to be vigilant in case importing language from elsewhere - whether from common-sense, academic theory, health service managers or politicians - reduces their autonomy and their ability to care for patients. At a time when nursing is hungry for more powerful conceptual and linguistic tools to make sense of its situation, the critical stance afforded by reflective practice can help nurses develop their own sceptical and ethical faculties. It also enables nurses to uncover and challenge their own personal values and prejudices. Taken together, these features will help ensure that nursingís language is a powerful ally of nurses and patients.
If we are to take the challenge of reflective practice seriously, it must address nursing on a number of fronts. Nurses need to become increasingly aware of the textually transmitted values currently being communicated in nursing. Nurses need to examine more critically the language that is used to describe their practice rather than passively accepting regulated vocabularies and categories concerning what it is they do. Reflective practice, at its best, can enable us to understand the controlling influence of language. Moreover, it can empower nurses to resist contemporary threats to the core values of nursing which come via language couched in management terms, and resist threats to the profession posed by naive schemes to try to define all the words in nurses' vocabularies. Without this reflective ability nursing can become the instrument of politically driven health agendas which promote a task-focused service, which does not sit very well with the caring, compassionate philosophy on which it has always prided itself. The challenge of reflective practice must not be ignored.
Notes and references