Sensitivity is an essential component of health care communication (Institute for Health Communications, 2011), and it is well documented that communication is a vital medium for empowering patients to achieve and maintain optimal health. Effective communication has been found to influence patients' self-management of medical conditions, adoption of preventive behaviors, and satisfaction and quality of care (Institute for Health Communications, 2011). Health care providers must be able to demonstrate an awareness and understanding of their patients' feelings regardless of their patients' situation; diagnosis; or social, emotional, cultural, or intellectual backgrounds. By doing so, they are better able to develop and sustain a therapeutic provider– patient relationship (Entwistle, 2008). The following real case demonstrates a lack of sensitivity by a health care provider:
A patient presented to her provider with increased swelling and pitting edema to her left foot. While sitting on the examination table, the provider greeted the patient and stated, “Let me see your Fred Flintstone foot.” The patient was offended; people had referred to her foot as “big” before but never to this extent. She did not confront the provider, nor did she return for follow-up care. (Fred Flintstone is known for his large, wide feet [Brandt & Cervone, 2015]).
This case demonstrates how the language used by a provider, whether intentional or not, can be perceived by a patient as insensitive and affect follow-up care. In cases such as this one, continuing education is needed to improve provider–patient communication and thus enhance patient care and satisfaction with care (Institute for Health Communications, 2011).
For nurses, sensitivity is particularly important because in many institutions, nurses are responsible for the majority of patient care. The importance of sensitivity holds even more significance because in many institutions, one of the measures of quality of care is patient satisfaction (Centers for Medicare and Medicaid Services, 2014). Satisfaction surveys typically include questions about courtesy, respect, and providers' use of condescending, sarcastic, or rude tones with patients (Centers for Medicare and Medicaid Services, 2014). Interactions poorly perceived by patients regarding psychosocial issues have been strongly associated with unfavorable ratings of care (Agoritsas, Bovier, & Perneger, 2005). In consideration of these communication outcomes, nurses need to choose words carefully regarding their patients, as some words may be perceived as lacking language sensitivity.
Based on practical experiences in nursing and a literature search, a variety of words and phrases were identified that, when used in certain contexts, could be deemed insensitive. However, an overarching concept was not identified that could be used to label and explain this type of sensitivity, nor was there a synthesis of these words and phrases in the literature. Therefore, the purpose of this article is to (a) propose language sensitivity as a concept; (b) present examples of how language sensitivity may be lacking in nurse–patient interactions and provide solutions using Bejciy-Spring's (2008) RESPECT (Rapport, Environment/Equipment, Safety, Privacy, Encouragement, Caring/Compassion, and Tact) model as a framework; and (c) offer nurse educators strategies to inform or remind nurses how to promote language sensitivity in patient care.
Language sensitivity is proposed as an emerging concept in health care that can augment the importance of sensitivity in patient care. Language sensitivity is defined as the use of respectful, supportive, and caring words with consideration for a patient's situation and diagnosis. To support the need for the concept and its early definition, the differences between language sensitivity and other sensitivity concepts are presented, followed by a description of the different aspects of language sensitivity using an existing sensitivity framework.
Sensitivity is a key concept in patient care that has evolved into more specific concepts (Table 1), including cultural sensitivity (Foronda, 2008), ethical sensitivity (Weaver, Morse, & Mitcham, 2008), moral sensitivity (Baykara, Demir, & Yaman, 2015), and gender sensitivity (Celik, Lagro-Janssen, Widdershoven, & Abma, 2011). The commonality identified in the definitions of these sensitivity concepts is an individual's ability to recognize and respond appropriately to human differences and to distinguish appropriate behavior from inappropriate behavior. For each of these concepts, different models and programs have been developed to provide sensitivity education or training for health care providers.
Sensitivity Concepts in Health Care Defined
Language sensitivity varies from the other sensitivity concepts because it focuses on the specific words used when interacting with patients. For example, in a concept analysis of cultural sensitivity, the attributes of knowledge, consideration, understanding, respect, and tailoring were associated with effective communication (Foronda, 2008). Communication is an attribute of cultural sensitivity; however, language is not detailed in the concept of cultural sensitivity. In addition, language sensitivity is not always culturally specific. Although language sensitivity may be implicit in these concepts, no detailed descriptions or examples were found.
The Respect Model
The RESPECT model was developed by Bejciy-Spring in 2008 to support the National Association of Bariatric Nurses mission to improve nursing care for individuals experiencing obesity. The goal was to provide a framework for nurses to “provide quality, patient-centered, sensitive care to patients undergoing bariatric procedures” (Bejciy-Spring, 2008, p. 47). RESPECT stands for Rapport, Environment/Equipment, Safety, Privacy, Encouragement, Caring/Compassion, and Tact. These concepts were derived from the personal experiences of a patient who had undergone a bariatric surgery and are described in detail in Bejciy-Spring's (2008) seminal article. All patients deserve respect, and the RESPECT model provides a framework for promoting a culture of sensitivity. The concepts in the RESPECT model are used, with permission, to describe the different aspects of language sensitivity (Table 2) and its potential application in nursing education (Table 3) and the care of all patients. The model also is used to underscore the negative outcomes potentially associated with language used by providers that lacks sensitivity. The same concepts within the model are used in this article; however, the description that follows each concept was adapted to address language sensitivity.
The Respect Model and Language Sensitivity
Lesson Plan for Promoting Language Sensitivity in Health Care Using the Respect Model
Acknowledge Each Patient as an Individual and Not Based on His or Her Condition or Disease. Language can be stigmatizing when it sets an individual apart, leading to stereotyping and discrimination (Government of Western Australia Mental Health Commission, 2009). Language sensitivity is not present when providers use the names of stigmatizing diseases or disorders (e.g., psychiatric disorders, obesity, HIV/AIDS, substance abuse) to label patients. When terms are used that place an illness before the patient, such as mentally ill patient or heart failure patient, the illness dominates the person (Shattell, 2009). Referring to individuals with schizophrenia as schizophrenics or individuals with paraplegia as paraplegics are additional examples. Person-first language can help to minimize this stigma by placing emphasis on the person rather than on his or her illness or disability (Jensen et al., 2013). For example, the statements patient with heart failure and person with paraplegia are more appropriate. Resources for words to avoid and alternatives are available for reducing the stigma associated with addiction (National Alliance of Advocates for Buprenorphine Treatment, 2008), obesity (Dutton et al., 2010; Puhl, Peterson, & Luedicke, 2013), and mental illness (Shattell, 2009).
Be Prepared and Aware of the Language Used When Communicating Patient Care Needs Regarding the Environment and Equipment. One of the most stigmatizing diseases in health care is obesity. Patients who are overweight or obese often require different resources, equipment, and procedures (Bejciy-Spring, 2008), and when these needs are acknowledged in the presence of these patients, it may cause them to feel they are being treated inhumanely. Examples include referring to larger wheelchairs and hospital beds as “big boys” (HCpro Inc., 2009, p. 1) or saying, “We're going to need some more muscle to turn him/her” and “I need to use the oversized blood pressure cuff on you.” To avoid these mishaps and promote language sensitivity, nurses should conduct a thorough assessment of their patients and be prepared to care for those with unique physical, comfort, and safety needs (Bejciy-Spring, 2008; Fruh et al., 2016; HCpro Inc., 2009). Recognizing the need for larger blood pressure cuffs, chairs without arms, or plus-size hospital gowns in advance and having them available will prevent the nurse from having to verbalize the equipment needs once in the room (HCpro Inc., 2009).
Understand That When Language Sensitivity Is Lacking, It May Contribute to Negative Psychological and Behavioral Outcomes. A concern exists for patient safety when language prompts negative or inappropriate patient responses (Kuzel et al., 2004), such as anxiety, depression, or avoidance of health care. In the earlier examples, stigmatizing or disrespectful language can be a source of embarrassment, leading to the mistrust of health care providers and impairment of one's willingness to seek and receive health care or comply with treatment (Corrigan, Druss, & Perlick, 2014; Institute for Healthcare Communications, 2011). A threat to safety also can occur when statements are made that do not allow patients to express their true feelings. An example of this would be a nurse who states, “You do not want to hurt yourself again, do you?” to a patient receiving treatment for attempted suicide. Patients may not want to admit their suicide ideations because of shame or guilt and then isolate themselves, further putting them in a dangerous situation. An alternative approach using language sensitivity would be to express concern about patient safety, state how the health care team wants to help, and ask in a matter-of-fact way whether patients are experiencing thoughts to hurt themselves or anyone else.
Finally, the use of language that labels an individual's body part as abnormal can be distressing, and subsequent camouflaging (with body position and clothing) of the body part, a symptom associated with body dysmorphic disorder, may be observed (Anxiety and Depression Association of America, 2016). When individuals have difficulty coping with their physical appearance, the result may be nursing diagnoses of disturbed body image, self-esteem disorder, and social isolation, which require special care.
Be Mindful Not to Disclose Sensitive Health Information, Such as During Medication Administration. A lack of language sensitivity can occur when nurses refer to medications using the name of the stigmatizing disease for which the medication is being taken. For example, such a statement would be, “It's time to take your HIV medication.” Acknowledgement of the stigmatizing disease may be uncomfortable for the patient, and the discomfort may be heightened when it occurs in the presence of a patient's visitors or ancillary personnel, who may not be aware of the patient's diagnosis. Another example of such statements is, “Here is your happy pill.” In addition to the issue of privacy, this statement implies that the patient has depression and minimizes the significance of the disease. The better alternatives for these statements are to replace HIV with antiretroviral and happy with mood. It also is important for nurses to use words that are familiar and understandable by their patients; this may be accomplished by stating the name of the medication and asking patients how they refer to the medication or how it is intended to help them.
Use Words That Encourage Rather Than Discourage Patients. When health care providers use words such as bad or big to refer to body parts, the language can be offensive to patients and lack language sensitivity. Bad and big are commonly used words in the English language, and providers may unintentionally use these words, not knowing how the words are perceived by patients. Bad and big are also lay terms that are often understood by patients, but the negative connotation of these words may outweigh simplicity in certain situations. For example, for a patient with upper extremity weakness following a stroke, instead of referring to the extremity as the bad arm (e.g., “raise your bad arm”), use right or left or weak, or point to the arm. The same for a patient with lower extremity lymphedema or cellulitis, instead of labeling the leg as big (e.g., “let me see your big leg”), use right or left or swollen, or point to the leg. Using the words bad, big, or even small acknowledges the patient's imperfection, which could affect his or her self-esteem. Additional words to avoid include clean and dirty when referring to results of tests that detect the presence of specific drugs; the alternatives are negative and positive (National Alliance of Advocates for Buprenorphine Treatment, 2008).
Caring and Compassion
Avoid Using Inappropriate Terms of Endearment When Addressing Patients. Often, terms that appear to be affectionate or endearing and used to establish therapeutic relationships can, in fact, be perceived as patronizing and lacking language sensitivity. When patients are addressed as honey, sweetheart, darling, or love, they may feel uncomfortable, disrespected, or disempowered (Draper, Wray, & Burley, 2013). These terms are considered informal and unprofessional when used in the health care setting and can make adults feel childlike and subservient. Alden and Toth-Cohen (2015) discuss the effects of ageist attitudes by health care professionals, describing how terms of endearment and infantilizing communication can negatively affect an older adult's sense of self-worth. To show respect and create a trusting relationship, patients should be identified by their title (e.g., Mr., Miss, Mrs., or Dr.), followed by their last name, unless nurses are invited by their patients to address them differently.
Always Think Before You Speak to Avoid Offending Patients. In the original RESPECT model (Bejciy-Spring, 2008), nurses are encouraged to use tact by recognizing that terms such as large size, obese or obesity, and fat or excess fat may offend patients and instead use the preferred terms unhealthy weight, high BMI [body mass index], weight problem, or excess weight (Dutton et al., 2010; Puhl et al., 2013). In addition, using inanimate objects to identify or describe patients or their body parts also can be problematic and lack language sensitivity. For example, comments such as, “She's as big as a house” or “You look like you're going to blow” have been used to describe women who are pregnant. For some, terms such as Fred Flintstone foot are thought to be a form of humor. Humor is a communication skill that when used appropriately can help to develop the provider–patient relationship and reduce stress and anxiety (Tremayne, 2014). However, when used inappropriately, humor can have the opposite effect. Providers must have a good sense of their patients to know if and when to use humor.
Incorporating Language Sensitivity in Nursing Continuing Education
Language sensitivity and the RESPECT model can be used by nurse educators, as well as continuing education and staff development professionals, to enhance communication and interpersonal skills among nurses. These concepts can be incorporated into education sessions for new nurse hires and for annual competencies for staff nurses. A variety of educational approaches can be used to promote language sensitivity, including journal clubs, handouts and poster board presentations, case studies, and simulation. Table 3 provides a sample lesson plan addressing language sensitivity using the RESPECT model.
Journal clubs can promote the professional and personal development of nurses and can stimulate discussions about topics of importance (Häggman-Laitila, Mattila, & Melender, 2016). Articles such as this one that address sensitivity in patient care can be selected for a hospital or unit journal club or assigned as reading material for an in-service program. A discussion of the article can follow with participants providing their own examples of language sensitivity or insensitivity.
Handouts and Poster Board Presentations
Handouts and poster boards can be developed by nurse educators, nursing staff, or nursing students. The descriptions of language sensitivity and the concepts of the RESPECT model can be displayed in the handout or on a hospital unit board as reminders of effective nursing communication.
Case Studies and Simulation
Case studies and high-fidelity simulation have been shown to facilitate the transition of new nurse graduates to clinical practice (Roche, Schoen, & Kruzel, 2013) and to increase self-efficacy of nurses in clinical practice (Christian & Krumwiede, 2013). Both techniques provide opportunities to present complex patient situations to nurses in a safe and nonthreatening venue, and can be used for competency-based training in clinical settings. The case study provided at the beginning of the current article and the one below can be used to stimulate nurses' thinking about language sensitivity and application of the RESPECT model. The case studies can be placed on a PowerPoint® slide or a handout for nurses to read, followed by a question-and-answer session and discussion. Nurses can be asked to identify the use of ineffective communication, discuss what is problematic, and modify the scenario to promote optimal communication.
A patient with a history of morbid obesity is admitted to the hospital with pneumonia. A nurse and patient care technician enter the patient's room to give him a bed bath. This is the first time the two have cared for the patient, and after introducing themselves, the nurse calls to the nurses' station and says, “I am going to need about five more people to come in and help me bathe this patient.” The patient gets upset and responds emotionally, “I know how to turn myself in the bed and I can bathe most of myself, but you never asked me.”
The same case studies and other examples described also can be used for simulation activities. Studies have demonstrated the effectiveness of using simulation as an instructional method for communication (Kelly, Berragan, Husebø, & Orr, 2016; O'Hagan et al., 2014). Educators can develop original live or recorded simulations with scenarios of health care providers demonstrating a lack of language sensitivity while caring for standardized patients. The same content also can be incorporated into existing scenarios to provide an additional dimension regarding nursing communication.
In the strategies described, educators can provide the definitions for sensitivity, language sensitivity, and the associated concepts identified in this article. An in-service or huddle discussion can be used to compare and contrast the different types of sensitivity, or educators can develop a simulation activity with the sensitivity concepts for nurses to identify. Nursing diagnosis and care plan development can be integrated to promote thinking through the nursing process. Further learning of how to assess and care for patients experiencing disturbed body image, self-esteem disorder, and social isolation can be included. Finally, nurses should be aware of the components of patient satisfaction surveys and how communication may be perceived by patients.
When caring for patients, extra care should be taken to use words and phrases that are not offensive, demeaning, or stigmatizing. Some factors involved in word choice include simplicity, norm, and intent to promote humor or compassion; however, nurses should consider the negativity that some words may conjure. A lack of language sensitivity may endanger the nurse–patient therapeutic relationship and negatively influence a patient's mental and physical well-being, and in some cases, his or her privacy.
Language sensitivity, the use of respectful, supportive, and caring words with consideration for a patient's situation and diagnosis, is an emerging concept that can enrich nursing terminology and expand nursing practice, research, and education. Further work is underway to fully synthesize and conceptually define language sensitivity. Nonverbal language sensitivity, such as using eye contact and social touch (Henry, Fuhrel-Forbis, Rogers, & Eggly, 2012) and providing warmth and understanding (Montague, Chen, Xu, Chewning, & Barrett, 2013), was beyond the scope of this article and also deserves consideration and further exploration.
Being an effective and compassionate communicator is a skill that can be learned. Nurse educators can create a culture of awareness using the concept of language sensitivity, the RESPECT model, and examples provided as tools to enhance nursing communication. Language sensitivity education may improve nurses' communication skills and increase their understanding of the needs and concerns of their patients. It is a concept that can easily be incorporated into nursing communication education in a variety of practical ways. Nurses are expected to role model professional behavior for other team members, particularly for those with less education and training, such as nursing assistants, support staff, and nursing students. Nurses should strive to create a supportive, empathetic environment for their patients by using suitable words and phrases that do not threaten the self-RESPECT of their patients.
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Sensitivity Concepts in Health Care Defined
|Cultural sensitivity||“Employing one's knowledge, consideration, understanding, respect, and tailoring after realizing awareness of self and others and encountering a diverse group or individual.” (Foronda, 2008, p. 210)|
|Ethical sensitivity||The capacity to anticipate consequences and act with intelligence and compassion, using an understanding of codes for ethical conduct, clinical experience, and knowledge (Weaver et al., 2008).|
|Moral sensitivity||“An ‘attention’ to the moral values involved in a conflict-laden situation and a self-awareness of one's own role and responsibility in the situation.” (Lützen, Dahlqvist, Eriksson, & Norberg, 2006, p. 189)|
|Gender sensitivity||“The competence to perceive existing gender differences and incorporate these differences into decisions and actions by health care professionals.” (Celik et al., 2011, p. 143)|
|Language sensitivity||The use of respectful, supportive, and caring words with consideration for a patient's situation and diagnosis.|
The Respect Model and Language Sensitivity
|RESPECT Model Concept||Description of Concept||Specific Example|
|Rapport||Acknowledge each patient as an individual and not based on his or her condition or disease.||Use person-first language; say “patient with heart failure” rather than “heart failure patient.”|
|Environment/Equipment||Be prepared and aware of the language used when communicating patient care needs regarding the environment and equipment.||Have available specialized equipment (e.g., larger blood pressure cuffs) and avoid the use of words (e.g., “plus size,” “big boy”) that acknowledge a patient's condition.|
|Safety||Understand that when language sensitivity is lacking, it may contribute to negative psychological and behavioral outcomes.||Be aware of the negative outcomes (e.g., anxiety, depression, avoidance of health care, camouflaging) that may result from a lack of language sensitivity.|
|Privacy||Be mindful not to disclose sensitive health information; for example, during medication administration.||Use words that do not identify patients' stigmatizing diseases, especially during medication administration.|
|Encouragement||Use words that encourage rather than discourage patients.||Use “right” or “left” or “swollen” or “weak” instead of “big” or “bad” when speaking of body parts.|
|Caring and Compassion||Avoid using inappropriate terms of endearment when addressing patients.||Address patients by their title and last name instead of “honey,” “sweetheart,” “darling,” or “love.”|
|Tact||Think before you speak to avoid offending patients||Get to know your patients to determine if and when to use humor|
Lesson Plan for Promoting Language Sensitivity in Health Care Using the Respect Model
|Goals of the Lesson:|
|Cognitive: Nurses will be able to understand and apply the concept of language sensitivity during nurse–patient interactions. The RESPECT model will guide nurses' application of language sensitivity during nurse–patient interactions. Nurse educators will be able to promote strategies to inform or remind nurses how to promote language sensitivity in patient care.|
Define language sensitivity.
Describe the purpose and significance of language sensitivity.
Develop strategies to promote language sensitivity in patient care.
|Objective||In-Service Outline Content||Resource and Activity||Evaluation|
|1. Define language sensitivity.|
Present the concept of sensitivity and how this concept has evolved into more specific concepts in nursing.
Explain how language sensitivity differs from other sensitivity concepts.
Celik et al. (2011)
Weaver et al. (2008)
Lützen et al. (2006)
|2. Describe the purpose and significance of language sensitivity.|
Discuss the RESPECT model.
Describe how a lack of language sensitivity during nurse–patient interactions may affect patient outcomes.
Ask nurses to reflect on and discuss how a patient may feel in the following instances:
When a nurse does not acknowledge the patient as an individual but as his/her condition or disease;
When a nurse is not aware of the language used when communicating patient care needs related to the environment and equipment;
When nurses use inappropriate terms of endearment.
A unit-specific module can be made to represent cases that reflect the patient population.
|3. Develop strategies to promote language sensitivity in patient care.|
Describe educational approaches, such as journal clubs, handouts, poster presentations, case studies, and simulation.
Have nurses participate in a simulation where language sensitivity is not present and discuss the potential impact it may have on the patient.
Have nurses watch a short video where language sensitivity is not present and discuss the potential effects it may have on the patient.
Have nurses document all instances where language sensitivity is not present.