Posted the first week of March, which is designated as
National Words Matter Week
A long time ago, I read an editorial in a journal decrying the labels for women’s reproductive health issues. The point was that labels such as incompetent cervical os are pejorative words. At about the same time, I began to think about what we mean when we say that a person (called a patient or a client) does not comply with or adhere to a treatment plan. It seems to me that these words reflect the physician’s or the nursologlist’s prescriptions for the patient, which in turn, reflect the physician’s or the nursologist’s power over and control of the patient.
Indeed, Hess (1996) pointed to “connotations of paternalism, coercion, and acquiescence” (p. 19), and Bissonnette (2008) and Garner (2015) noted the power imbalance and loss of patient autonomy inherent in referring to a patient as non-compliant or non-adherent. I doubt that few if any nursologists would knowingly sanction paternalism, coercion, acquiescence, power imbalances, and loss of patient autonomy. Yet we continue to label patients as compliant or adherent if they do whatever they were supposed to do and as non-compliant or non-adherent if they do not do whatever they were supposed to do.
The issue, of course, is to identify a label that can be used to accurately reflect what happens between a person who is a patient and a person who is a healthcare worker as they interact in matters of health without an overlay of paternalism, coercion, acquiescence, power imbalance, or loss of autonomy.
Most, if not all, nursology conceptual models and theories include consideration of the person’s perspective of the health-related situation and may include a process that addresses how the situation is viewed and resolved. For example, the practice methodology associated with Neuman’s Systems Model includes the perspectives of both the person and the healthcare worker throughout the entire process of diagnosis, goals, and outcomes. The practice methodology associated with King’s Conceptual System is even more explicit, with mutual goal setting, exploration of means to achieve goals, and agreement on means to achieve goal. However, the practice methodologies associated with these nursology conceptual models and theories do not include a label for what happens if the patient does or does not do what had been agreed upon.
I have not yet identified a satisfactory label for what actually happens. However, I suspect that turning to nursology theories of power may provide at least the beginning of an appropriate label. For example, Barrett’s theory of power as knowing participation in change sensitizes us to the distinction between power-as-control and power-as-freedom. Barrett maintained that power-as-freedom involves awareness of what is happening, knowingly participating in choices to be made about what is happening, having the freedom to act intentionally, and being fully involved in creating changes in whatever is happening. Perhaps, then, the label could be knowing participation.
Another example is Chinn’s peace as power theory, which sensitizes us to the distinction between peace-power and power-over. The process of peace as power encompasses cooperation and inclusion of all points of view in making decisions. Accordingly, healthcare decisions are based on thoughtful choices as the person and the healthcare worker work together to promote wellness and growth. Perhaps, then, the label could be thoughtful cooperative choices.
What other label might be even more accurate? How can nursologists actualize our moral goal to do “good for the one for whom the [nursologist]” cares”? (Hess, 1996, p. 19). What label should we use to clearly reflect our ethical knowing? Hess’ (1996) discussion of ethical narrative suggests that cocreated narrative may be the accurate term. She explained, “ethical narrative is crafted by the client and [nursologist] to express the good they are seeking” and that ethical narrative is achieved “through engagement” (p. 20).
Labels, which are words, matter for many, many reasons. Labels may reflect paternalism, coercion, acquiescence, power imbalances, and loss of patient autonomy. Labels also may reflect racism and privilege and other words that perpetuate colonialism (McGibbon, Mulaudzi, Didham, Barton, & Sochan, 2014). We must, therefore, identify and consistently use labels that are consistent with ethical knowing in nursology, with clear understanding of “their meanings and the underlying philosophies or perspectives that they connote” (Lowe, 2018, p. 1).
This blog is adapted from Fawcett, J. (in press). Thoughts about meanings of compliance, adherence, and concordance. Nursing Science Quarterly.
Bissonnette, J. M. (2008). Adherence: A concept analysis. Journal of Advanced Nursing, 63, 634-643. Available from: http://dx.doi.org/10.1111/j.1365-2648.2008.04745.x
Gardner, C. L. (2015). Adherence: A concept analysis. International Journal of Nursing Knowledge, 26, 96-101. Available from: http://dx.doi.org/10.1111/2047-3095.12046
Hess, J. D. (1996). The ethics of compliance: A dialectic. Advances in Nursing Science, 19(1), 18-27.
Lowe, N. K. (2018). Words matter. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 47, 1-2. Available from: http://dx.doi.org/10.1016/j.jogn.2017.11.007
McGibbon, E., Mulaudzi, P. M., Didham, P., Barton, S., & Sochan, A. (2014). Toward decolonizing nursing: The colonization of nursing and strategies for increasing the counter-narrative. Nursing Inquiry, 21. 179-191. Available from: http://dx.doi.org/10.1111/nin.12042 (See also https://nursology.net/2020/01/14/decolonizing-nursing/)