Nursing
From 2000 - 2002 the Language in the Workplace team investigated nurse/patient interactions at a New Zealand hospital. The primary objective was to pilot a methodology suitable for collecting data on spoken interactions between a nurse and their interlocuors during different shifts in a given week. Another objective was to investigate the suitability of the methodology as one that could be used in a wide range of professional contexts (for example private homes and medical centres).
Two contrasting features of interaction feature here as foci for analysis, directives and humour.
Directives
Humour
Publications
It is possible to give a directive in a wide variety of linguistic ways. The most direct is to use an imperative form: eg.flex your arm. At the other end of the spectrum, in the least direct form the person addressed usually has to infer what the speaker wants. However, the specific context in which the nurse is talking often means her intention is quite obvious so that not much guesswork is involved:
eg. a nurse to a doctor:
I was just wondering if she could have some drugs to settle her down
The doctor doesn't need to be a linguistic expert to work out what the nurse wants in this case.
Less direct forms are generally regarded as more polite. It is also widely accepted that, all other things being equal, the use of more direct forms indicates that people know each other well, or alternatively that one has the right to tell the other to do something eg. staff nurse to nurse aide. Between a nurse and a patient one might expect relatively polite forms, and similarly between a nurse and a doctor, but of course the context is always important. Between a nurse and a patient one might expect relatively polite forms, and similarly between a nurse and a doctor, but of course the context is always important. More polite forms are generally longer, and one would not want to take a lot of time in an emergency, nor even when things were very busy. Moreover, the precise power relationships between particular nurses and particular doctors are not predictable by any formula, because so many different variables may be relevant to the analysis (eg. experience, age, gender, personality, etc). In the analysis which follows, we illustrate the nurses' sociolinguistic skills in taking account of such factors in selecting from a wide range of forms to express directives appropriately in interaction with patients.
Focussing on nurse-patient interaction, among the most interesting findings was
- the extent to which nurses softened their directives to patients so that they were clear but polite, and
- the wide range of devices that nurses used for this purpose.
In this preliminary study we identified just 20 directives in the 102 minutes of recorded transcribable interaction between nurses and patients. The small number is interesting since one might have expected many more instructions from nurses to patients in nearly two hours of talk. In fact we found that more than half the talk between nurse and patients was social talk, designed to establish good relations and make the patient feel comfortable and appreciated as an individual.
Directives can be expressed using one of three broadly different structures:
- Imperative: eg. relax your arm
- Interrogative: eg. can I pop this probe under your tongue?
- Declarative: eg. we'll need to get you up to get to the loo soon
The majority (70%) of the directives used by the nurses in our data were imperative in structure: eg lift your arm, keep pressure on that. This surprised us initially, since imperatives are generally considered a rather authoritarian and “bossy” linguistic structure, and the overall impression of the nurse-patient interactions in our data was quite the opposite. The nurses seemed very polite, considerate and friendly.
When we looked more closely at the data, we discovered that every imperative was softened or attenuated in some way. Further analysis revealed that, in fact, every single directive in the data included at least one pragmatic softening strategy. Moreover, the nurses drew on a wide range of such strategies. In the next section we identify some of the linguistic devices nurses used to soften their directives.
Softening a directive: linguistic strategies
Nurses used a wide range of different kinds of linguistic strategies to soften their directives, including grammatical devices and lexical items. In the examples below, the softening devices are in italics. The unsoftened version of the directive is provided in brackets for comparison.
(i)"if " clauses
"If" clauses are traditionally considered to be conditional clauses "if X then Y".
In the hospital data if often functioned as a softener like now or justrather than as a conditional conjunction.
(1)so if you take those I'll be back in a minute (vs take those)
(ii) Pronoun choice
The pronoun usually associated with directives is you, as illustrated in (1). Another device used to soften a directive was to use a different pronoun such as we or us or there. The effect is to soften the directive.
(2)we'll need to get you up to get to the loo soon (vs you need to get up…)
there's nothing to eat or drink after midnight ( vs you mustn't eat or drink..)
Most nurses will be unaware of their linguistic choices, yet the effect they have is very significant in terms of making patients feel comfortable and cared for. The very wide range of softening devices used in our small sample of interaction indicates considerable linguistic sophistication, as well as the nurses' sensitivity to the contextual factors relevant in their exchanges with patients.
The second area we have selected in order to illustrate the sociolinguistic skills developed by nurses is the way they use humour in their interactions. Humour serves many functions. It is yet another strategy which can be used to soften a directive, but humour also maintains and develops good relationships between people, and enables them to express feelings or views they might not get away with otherwise. Friendly humour: to help patients feel more relaxed.
One important function of humour in the interactions between nurses and patients was to reduce the stress of a potentially uncomfortable situation, and to help their patients to feel more relaxed. There are many examples of this in our data; here we discuss just one.
In excerpt 1 Sophie, a patient, expresses some anxiety about the anticipated removal of a cannula (a small device giving access to a vein). Earlier in the day, Tara, the nurse, had removed a large drain from a wound which had been a painful and distressing experience for Sophie.
Excerpt 1
Context: The nurse comes into the patient's room to take out a cannula
Tara:and I'll take out your cannula + sorry
Sophie:this is just a little thing eh not like the other
Tara responds to Sophie's worry by reassuring her and then introduces the topic of Sophie's leaving hospital soon. Sophie tells Tara that she will stay with her parents initially, since her flat is being decorated. Excerpt 2 illustrates the way in which Tara skilfully distracts Sophie from the unpleasant medical procedure she is undergoing.
Excerpt 2.
Context: The nurse is in the patient's room taking out a cannula. [The words between slashes/\ indicate overlapping talk].
Sophie: so I’m staying with mum and dad
Tara:wicked yeah
Sophie: yeah
Tara: a few home comforts don’t /hu- don’t hurt\
Sophie: /oh mum would\ insist on it even if I don’t want to /she’d insist yeah [laughs]\
Tara: /yeah [laughs]\ mothers have that right /don’t they\
Sophie: /they do\
Tara: yeah /okay\
Sophie: /well I don’t mind\ cos I get treated like a queen /so [laughs]\
Tara: /exactly \ lap it up
During all this talk, Tara is taking out the cannula. Her colloquial friendly chat, full of humour, helps distract Sophie from the discomfort involved. The overlapping talk indicates the informality and good rapport between the two young women. The talk focusses on Sophie, and on the comfort and care she can look forward to from her mother when she leaves the hospital. The two women establish a collusive bond, expressing a shared wry, yet appreciative, attitude to the way mothers fuss over their daughters. Establishing friendly rapport like this obviously helps the patient feel more relaxed in this clinical setting, and this clearly assists the nurse achieve her goals as well.
Subversive humour: to soften a criticism
Humour is often used to soften negative messages (Holmes 1999). In many workplaces where we have observed, humour was used to soften criticism, for instance. It is particularly useful when an individual wants to express a critical comment to someone whom they don't wish to offend, such as a close colleague or someone in a position of power, for instance. We found a number of examples of humour used this way by the nurses in our sample.
One example occurred in a context where two staff nurses had been waiting for some time for the doctor to arrive. They were getting very irritated by the fact that he was so late coming up to the ward, as excerpt 3 illustrates.
Excerpt 3
Context: Two staff nurses, Tracey and Rebecca, are talking in the nurses' station while they wait for the doctor to arrive.
Rebecca: I wonder where André is
Tracey: well he said an hour and I think he's been longer than an /hour so I'm I'm not\ happy with that
Rebecca: /no I know\ I know
Tracey: gonna have to have a word with him about that…
not good time management
Rebecca: not good /time management\ that's right
Rebecca then pages the André and he returns her call
Telephone rings. Rebecca answers
Rebecca: hello ward fourteen staff nurse speaking
André are you coming up to war- [pause]
thank you very much /thank you bye bye\
Tracey: how long will he be
Rebecca: five minutes
Tracey: oh
Rebecca: [laughs] I know it's getting a bit desperate isn't it
Clearly both nurses are getting frustrated waiting for André to turn up. However, when he does arrive rather than "having a word with him" about his time management, as they threatened, they in fact turn their irritation into teasing André, as illustrated in excerpt 4.
Subversive humour provides a "socially acceptable cover" for criticisms of individuals, as well as for challenges of other sorts. Humour here allows the nurses to criticise the doctor in a non-threatening and acceptable way, which in turn relieves the tension which has been building up because of his lateness.
Nurses use humour regularly and constructively in their work. There are many examples in the data, with humour serving many different functions. In this section we have briefly illustrated just two contrasting functions: firstly the use of humour to relax a patient and assist the nurse in achieving her work objectives more efficiently; secondly the use of humour to relieve tension and thus maintain good workplace relationships between colleagues.
18 December, 2009
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©2009 Victoria University of Wellington, New Zealand |