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.
References
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/)
Marshall Rosenberg, in his book “Nonviolent Communication: A Language of Compassion” (1999) identifies labeling as a form of violent communication (pp. 15-19, 29). We’ve been working on this for a long time, haven’t we?
Ellen, Thank you for your comment. What does Rosenberg offer as an alternative to the word, label? Best regards, Jacqui
Rosenberg notes that we have become alienated from our natural state of compassion through the hierarchical system. “Blame, insults, put-downs, labels, criticism, comparisons, and diagnoses are all forms of judgment.” He says it is how we grew up, instead of being aware of and articulating our feelings and needs. He advocates observing without evaluating and honestly entering into dialogue, checking out the observations with the other. I understand it as being about the process of relating, not an alternative word.
Thought-stimulating words! Thank you! Two thoughts I am going to work on:
1. How would I answer your question from a Nursing As Caring perspective?
2. For those who use “the” nursing process or any nursing process, another step needs to be inserted, the step termed in the blog “co-created narrative”…in which the healthcare consultant and the person consulting with him/her engage in dialogue around the recommendations offered, within an environment of mutual respect and honesty, arriving at a mutually agreed upon plan led by the person seeking input.
Savina, Thank you very much for your comment. I look forward to your thoughts about labels from the perspective of Nursing as Caring. Best regards, Jacqui
Ellen, Thank you for your reply. I suspect that the main issue is to not use words to label people or things in a negative way. Taxonomies (such as for plants and animals) are made up of labels, so not all labels are necessarily negative but instead words that describe characteristics of “things.”
Thanks for this post (and your upcoming article!). I have been working with others on the language around diabetes for decades. Diabetes is one of those health situations where the messages are particularly negative, judgmental, shame/blame-based, and labels abound. In fact, diabetes may be the birthplace of the word “compliance” (control is another one)! In our work we are encouraging the use of “engagement” rather than “compliance” or “adherence,” and would love to hear other ideas as well. It is encouraging to see the conversation about words and messages expanding among broader groups and conditions.
Not to belabor the point, but words reflect thinking…and values. The healthcare consultant recommends a course of action from the “outside”, and it’s really the one seeking input that decides, and ideally the one seeking input welcomes the consultant’s input and engagement in dialogue in light of how the one seeking input sees the situation. Afraid many of our NP programs and practitioners are being taught the language of diagnosis, orders etc. Here’s where nursing theoretical frameworks come into play…or should…providing a well organized system of value, thought, language and action.
Thank you to Jane and Savina for your comments. Engagement is at least a good start to move us away from compliance and adherence. Savina’s point about who is seeking consultation and what that person does with the consultation certainly reflects what happens in the “real world.” I have found that people do what they can or what they prefer to do in matters of health regardless of what nursologisits or physicians tell them or advise them to do. My thought is that it is the nursologist’s ethical responsibility to provide options and potential outcomes of each option (or at least the options and outcomes we know about.
Another term to ponder is “primary care provider.” Perhaps Savina’s idea of the consultant works here–primary care consultant?